Spiritual Care Assessment Note (Hospice Chaplain)

Date/Time: [Date and time of visit]

Location/Setting: [home / SNF/ALF / inpatient hospice / hospital / phone / video]

Visit Type: [initial assessment / routine follow-up / PRN/crisis / vigil/actively dying / family-only / IDG input]

Participants Present: [Names and roles of those present, interpreter if used] (If patient unable to participate, state reason and identify collateral source.)

Reason for Visit

[Referral source and presenting concern] [Patient/family stated goals for chaplain involvement] (Limit to 1–3 sentences focusing on what prompted this encounter.)

Spiritual Care Acceptance

Offer and Acceptance: [Spiritual care was offered and: accepted / declined today / accepted by family only] (Use "declined today" rather than "refused.")

Preferences/Boundaries: [Stated preferences for spiritual care] (Only include if expressed; e.g., silent presence, no religious language, desires prayer.)

Community Clergy Coordination: [Desires coordination: yes / no] [Permission granted to share: yes / no / limited] [What may be shared] (Only include if clergy coordination discussed.)

If Declined: [Re-offer: yes / no] [Timing for re-offer] (Include only if spiritual care declined this visit.)

Participation Limitations: [Reason patient cannot participate and source of collateral information] (Include only when applicable.)

Spiritual Assessment

(Document in paragraph form integrating patient/family narrative with clinical synthesis. Use selective direct quotes for salient statements. State "not discussed this visit" for unknown information. Do not infer beliefs from identity cues; label clinical inferences and link to supporting observations.)

Spiritual Narrative and Context: [Patient/family spiritual story, values, sources of meaning, purpose, and hope]

Strengths and Resources: [Supportive practices, faith community involvement, relationships, prior resilience, coping strategies]

Needs or Distress: [Current spiritual/emotional concerns such as fear of dying, guilt, forgiveness needs, grief, loss of meaning, isolation, anger, unresolved relational issues]

Beliefs/Practices Affecting Care: [Faith tradition and importance, care-relevant beliefs or practices, ritual or sacrament requests] (Include only if discussed and relevant to care decisions.)

Family/Caregiver Spiritual Considerations: [Family or caregiver spiritual needs relevant to hospice goals or bereavement risk] (Include only when pertinent to care planning.)

Assessment Summary: [1–2 sentence summary translating findings into IDG-actionable problem statement with strengths and risks]

Interventions and Response

(List each intervention provided with patient/family response; use patient language when possible.)

• Intervention: [Supportive presence / reflective listening / spiritual reflection or life review / prayer or blessing / scripture or devotional reading / ritual facilitation / reconciliation support / anticipatory grief support / clergy coordination / IDG consultation / other]
  Response/Outcome: [Patient/family response and observed effect]
• Intervention: [Intervention]
  Response/Outcome: [Response]

(Add additional interventions as needed.)

Plan

• Patient-Centered Goals: [Specific goals with measurable elements when possible]
• Follow-Up: [Planned visit frequency and PRN triggers]
• Coordination Tasks: [Clergy scheduling, family meeting support, legacy project, ritual coordination] (Document attempted and successful coordination; note barriers.)
• Reassessment Targets: [What will be reassessed next visit]
• IDG Updates: [Updates communicated to IDG and relevance to interdisciplinary plan of care]

Safety or Ethical Concerns

(Include this section only if concerns are present.)

• Concern: [Self-harm statements beyond existential distress / suspected abuse or neglect / family conflict affecting care / coercion concerns / other]
• Actions Taken: [Immediate steps, notifications, safety measures]
• Escalation: [Persons notified and time of communication]

(Use patient-centered, non-judgmental language throughout. Do not document confessional content unless directly relevant to care planning or safety. Omit sections entirely when not applicable, except Spiritual Care Acceptance which must always be documented.)