This study examined patterns in chaplain documentation of assessments and interventions by analyzing records in an electronic health record system. The study found that chaplains preferred communicating using general themes and concepts rather than specifics about patient religion and spirituality. Additionally, the study found no consistent patterns among the assessments made or services provided by chaplains. This presents an opportunity for chaplains to develop a model of care that connects assessments to specific interventions and outcomes.

1. Abstract
PATTERNS IN CHAPLAIN DOCUMENTATION OF ASSESSMENTS AND
INTERVENTIONS, A DESCRIPTIVE STUDY
by Kevin E. Adams, MDiv
A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of
Philosophy at Virginia Commonwealth University, 2015
Diane Dodd-McCue, D.B.A, Department of Patient Counseling, dissertation chair
There is increasing emphasis on the importance of evidence-based care provided by all
disciplines in healthcare. The Electronic Health Record (EHR) is becoming the standard for
communicating assessments, plans of care, interventions, and outcomes of patient care. The
spiritual care literature demonstrates the importance of assessing religious/spiritual needs and
resources and developing plans of care to address the results of such assessment (Anandarajah &
Hight, 2001; Borneman, Ferrell, & Puchalski, 2010; Fitchett, 1999; Fitchett & Risk, 2009; H. G.
Koenig, 2007). This literature also suggests that addressing religious/spiritual needs of patients
and families in the healthcare context can affect healthcare and adherence outcomes. The
purpose of this study was to identify patterns of chaplain assessment and patterns of chaplain
provision of services.
This descriptive study was an exploratory retrospective analysis of categorical data
recorded by clinical staff chaplains in the EHR at a single all pediatric healthcare institution,
using contingency tables and frequency tables. The study examined chaplain use of assessment
and service descriptors and the patterns of these descriptors when documenting chaplain visits.
The results indicate chaplain preference for communicating in the EHR using general
themes and concepts. This reveals an opportunity for chaplains to develop and implement a
model of professional identity and articulation of care that is broad enough to accommodate the
diversity of religion/spirituality chaplains encounter, yet able to articulate the specifics of patient
and family religion/spirituality.
The results found no consistent patterns among assessments or services provided.
Further, the results found no indication of patterns between assessments made and the services
provided. This presents an opportunity for chaplains to develop and implement a theory-driven,
construct-based model of care that will connect the different facets of spiritual care. The
assessments made will lead to plans of care that involve specific interventions resulting in
appropriate outcomes related to overall patient and family care.