Spiritual Care Assessment Note (Palliative Care Chaplain)

Date/Time: [Date and time of encounter]

Chaplain: [Name, credentials]

Encounter Type: [initial assessment / follow-up]; [inpatient / outpatient / home]

Modality/Location: [in-person / telephone / video]; [Unit, room, or location]

Participants: [Patient participation status]; [Family/friends present with relationship noted]; [IDT members present]; [Interpreter: language and modality] (Include only those present.)

Referral Source/Reason: [Referring clinician or service and brief reason for consult]

Patient Capacity: [Ability to participate]; [Communication constraints and accommodations used] (Note orientation, cognitive status, fatigue, or sensory limitations if relevant.)

Reason for Consult

[Operational statement of consult question and need type] (1–3 sentences. State the presenting need clearly, e.g., spiritual distress, decision support/values clarification, ritual/sacrament request, anticipatory grief, family support. Avoid duplicating medical HPI.)

Spiritual Screening

[Screening status, outcome, and triage decision] (Document whether screening occurred this visit or previously; outcome: no distress identified / possible distress / significant-urgent distress. If patient declined, document neutrally and note plan to re-offer. Abbreviate if screening is stable and documented elsewhere.)

Spiritual History

[Patient self-described spiritual, religious, or existential identity and its importance] (Use patient's own language where possible.)

• Sources of meaning: [People, roles, values, activities, or beliefs that provide meaning]
• Community supports: [Congregation, clergy, or faith community]; [Contact requested: yes / no / undecided]; [Consent status]
• Current practices and rituals: [Prayer, meditation, scripture, sacred objects, observances]; [Setting constraints or accommodations needed]
• Beliefs influencing care: [Beliefs or practices impacting healthcare decisions] (Include only if relevant.)
• Family/cultural context: [Cultural or spiritual traditions shaping care and communication] (Include only if relevant.)

(If specific history elements were not obtained due to patient decline, fatigue, or time limits, document reason and plan to revisit.)

Spiritual Assessment

[Narrative summary of illness context as it relates to spiritual coping, central spiritual or existential themes, and expressed hopes and fears] (Use direct quotes sparingly for key meaning statements or explicit spiritual struggle. Distinguish observed/reported information from chaplain assessment.)

• Sources of meaning, purpose, and hope: [What still matters; important roles and relationships; legacy hopes; goals for remaining time; strengths and resources]
• Spiritual distress or suffering: [Loss of meaning, hopelessness, guilt, shame, anger at the sacred, fear of death or dying, abandonment, punishment, moral injury]; [Severity: mild / moderate / severe]; [Urgency if applicable]
• Existential concerns: [Questions of meaning in suffering; identity disruption; loss of autonomy; uncertainty]
• Relationships and belonging: [Reconciliation needs; family conflict; forgiveness themes; isolation; community connection]
• Practices, rituals, and preferences: [Supportive practices]; [Barriers in current setting]; [Preferences for touch, prayer language, who leads rituals, modesty, end-of-life customs]
• Grief and life completion: [Anticipatory grief; unfinished business; legacy work; goodbyes]

(Omit domains not relevant to this patient. If a relevant domain could not be assessed, note reason and plan to address.)

Chaplain Interventions

• [Interventions provided this encounter]

(List only interventions actually provided, such as: compassionate presence, empathic listening, guided reflection, meaning-centered conversation, life review, dignity/legacy support, prayer, meditation, blessing, scripture, sacred music, ritual facilitation, accommodations arranged, family support, participation in family meeting or goals-of-care conference. Do not document verbatim prayer or ritual content.)

Patient/Family Response

[Patient and family affect, engagement, and immediate changes observed] (Use phrasing such as "Patient stated…" or "Patient appeared…" Note if visit was declined or ended early.)

Spiritual Care Plan

• Working spiritual care concerns: [1–3 prioritized concerns, e.g., existential distress, religious struggle, anticipatory grief, ritual need]
• Goals: [Desired outcomes, stated in measurable terms when possible]
• Chaplain follow-up plan: [Frequency or interval]; [PRN triggers if applicable]
• Referrals and coordination: [Community clergy contact and consent status]; [Spiritual care volunteers, faith community resources, bereavement resources]; [Mental health or ethics referral if indicated]
• Rituals and accommodations requested: [What is requested]; [Timing relative to care]; [Who will lead]; [Arrangements needed]
• Recommendations to IDT: [Team members updated and communication method]; [Clinically relevant information shared: values impacting decisions, timing needs, family dynamics, communication preferences]; [Urgent notifications with recipient and time if applicable]
• Patient preference for ongoing spiritual care: [accepts ongoing care / declines ongoing care] (If declines, document criteria for re-offer.)

Safety and Escalation

(Include this section only if safety or escalation concerns are present; omit entirely otherwise.)

• Safety-related statements: [Exact patient wording indicating spiritual despair with safety concern, self-harm ideation, requests related to hastened death, or severe existential agitation]
• Immediate actions taken: [Who was notified with name and role]; [When notified]; [Interventions initiated]; [Disposition]
• Conflicts requiring consultation: [Belief-care conflicts]; [Ethics consult requested or considered]