Chaplaincy Documentation in a Large US Health System

Abstract

Chaplaincy documentation practices in the United States have evolved over time. Variation in practice remains. However, the trend in the profession is toward the expectation that chaplains will document their care. There is also an increased expectation regarding the content of that documentation. This paper highlights the history and current practice of chaplaincy documentation within the Memorial Hermann Health System in Houston, Texas, from the perspective of a spiritual caregiver working there. It includes a discussion of the “who, " “what, " “where, " “when, " “how, " and “why” of chaplaincy documentation. Memorial Hermann chaplains strive to document our care in a manner that bears witness to the holistic humanity of our care recipients. We also want to describe our care in a way that helps others understand the important ways professional chaplains contribute to the well-being of others. Chaplaincy documentation demands clarity, conciseness, care, and confidentiality and should be carried out in a manner one would wish for oneself or one’s loved ones if the roles were reversed.