SUSSEX PARTNERSHIP PROTOCOL

Chaplains and chaplaincy volunteers record keeping

Protocol Number
Protocol Version / 1
RATIFYING COMMITTEE / Professional Practice Forum
DATE OF eQUALITY & HUMAN RIGHTS IMPACT ASSESSMENT (EHRIA) / 1 October 2011 (assessed as not required)
DATE RATIFIED
NEXT REVIEW DATE / 30 September 2013
PROTOCOL SPONSOR / Executive Director of Nursing & Quality
Protocol Author / Multi faith and spiritual care team leader/ chaplain

Key Issues

This protocol describes a procedure for the multi faith chaplaincy team to contribute to the multi disciplinary team both on in-patient wards and CMHTs, to preserve the confidentiality and safety of service users, and to satisfy the needs of the Trust to monitor activity and equality assess this strand of activity.

The aim is to find a pattern of working that is safe, reliable, useful and not disproportionately time consuming, because the purpose of the team is to spend high quality face to face time with service users.

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1. Introduction:

This protocol describes a procedurefor the multi faith chaplaincy team to contribute to the multi disciplinary team both on in-patient wards and CMHTs, to preserve the confidentiality and safety of service users, and to satisfy the needs of the Trust to monitor activity and equality assess this strand of activity.

Scope: this protocol applies to paid and volunteer members of the chaplaincy team.

2. Aim

To find a pattern of working that is safe, reliable, useful and not disproportionately time consuming, because the purpose of the team is to spend high quality face to face time with service users.

3. Principles

  1. Chaplains work under contract to Sussex Partnership, and are bound by Trust codes of confidentiality, record keeping, consent and data protection. This protocol complies with current policy, and should be read alongside those current policies.
  2. Chaplains are an important part of multi disciplinary teams. They will often have in-depth conversations with patients, and may be entrusted with information that is significant to the care or treatment of a patient, or to the safety of other patients or members of the public.
  3. Chaplains need to have access to risk assessments and care plans so that they can work with the rest of the care team in the best interests of the patient.
  4. Information, observation and intuitions that chaplains gather whilst about their work are important parts of the overall picture of a service user’s risk level and possible routes into recovery. This information needs to be accessible to other members of the care team. The best way to do this is via both verbal reports to qualified staff and the in-patient care record or ECPA case notes.
  5. Chaplains are sometimes seen by service users as standing outside the normal multi disciplinary team. Chaplains do not accept this position, and will always make it clear that they are a full part of the MDT. They will not keep confidences, or “hear confessions” that are outside of normal NHS practices in handling patient information.
  6. The Equality Act 2010 enforces on NHS Trusts the responsibility to equality monitor all their services. Chaplains are a central part of the Trust resource around religion and belief. Their activity needs to be recorded and equality monitored, so that the Trust can demonstrate that its services are free from discrimination.
  7. The chaplaincy service costs the Trust approx £136k per year. Activity data is needed to justify this level of investment, and to assist with identifying areas of greater need than current resources can meet.

4. Procedure:

Inpatient wards

Currently most clinical information on inpatient wards is kept in hard copy files in ward offices. These files contain assessments, care plans, nursing notes etc. These files are used by the whole multi disciplinary team.

  1. Chaplains will explain to service users that they work as part of the ward team, and that they will add to the patient notes any information that is important to their care and safety, including the fact that a conversation has taken place since this forms part of the care record.
  2. Chaplains will make it clear to service users that they will not keep confidences from other members of the MDT.
  3. At the conclusion of a conversation or encounter, the chaplain will make an entry into the nursing/MDT care record in the usual format:
  4. Date, time. The time will indicate the timing of the contact and the time the note was written).
  5. Chaplain entry: with the relevant detail from the encounter.
  6. Signature and job designation: RHarlow, Chaplain.

Example

After contact with service users on the ward, this must be handed over to the nurse in charge or other qualified member of the nursing team

  1. The chaplain is not obliged to tell the patient what they are writing in the care record, nor is it necessary to agree with patients what is to be written in the care record. It is important that chaplains are able to write what they see, say and hear without needing to explain this to patients at the time. Patients may, however, request access to their care record through the usual process. Chaplains need to remember that their entries form part of a legal document, and may be seen by patients, or others acting on the patient’s behalf.
  2. Chaplains should make a note of all 1:1 conversations with a patient before leaving the unit in that patient’s care record, even if no new or significant information was disclosed. A simple note that the patient had 1:1 time with the chaplain, or attended a service/group, will be sufficient if no more detail is useful. It is not necessary to make a note in the care record if a chaplain speaks in passing to a patient (i.e. if a conversation lasts less than 5 mins, unless matters of substance were raised).
  3. Notes do not need to include the whole detail of a conversation. The key details are:
  4. When a conversation or episode of spiritual care took place
  5. What happened
  6. Information that seems relevant to the care or treatment of the patient
  7. Any actions that you will undertake as a result of the contact
  8. Any concerns that you have and to whom you communicated them.
  9. If a patient discloses information or displays behaviour which seems in the opinion of the chaplain to indicate risk to the safety of the patient or another person, this should be documented in the care record and the concern must be verbally communicated to a senior member of qualified staff. The chaplain should then document the name of the member of staff, their role and the time that the concern was raised.

Example

  1. Chaplains are not qualified to undertake risk assessments, therefore our entries to the care record should avoid appearing as though they are risk assessments. e.g. instead of “Steve appeared to be at very high risk of self harm”, you might say “Steve said that he felt suicidal 3 times in the meeting. I communicated this to John Smith, Charge nurse.”
  2. Chaplains should continue to keep a manual record of numbers of patients contacted each day for audit purposes.
  3. This data collection will not to be able to differentiate across all 6 strands of the Single Equality Scheme, but should record the Religion and Belief strand. At the moment the only viable way of producing these figures is for chaplains to attempt this differentiation themselves.
  4. If chaplains keep any aide memoires these must be anonymous so that it is impossible to identify any patient or any information about a patient from these notes. Aide memoires should be kept securely, and destroyed once they are no longer needed.

Chaplaincy Volunteers on inpatient wards:

Chaplaincy volunteers (CV) are subject to many of the same disclosures and interactions with service users as paid chaplains. However, because they are volunteers they will not have access to the patient care plan, assessments or care record. This poses some risk that their contribution will be lost to the care record, or that they will be frustrated in attempts to offer support by being largely “in the dark” concerning important aspects of the care plan and risk assessment.

This means that volunteers need to work with extra caution. They need to be careful that they are not perceived by patients to be “giving advice”. Instead they will mostly listen to and pray with patients, and they should consult staff if they are in doubt what to say to a patient.

The normal procedure for volunteers should be:

  1. The CV will ask ward staff for any relevant information about risk, safety or care before they start to visit a ward. They should ask if there are patients that have asked to see a chaplain, and any patient whom they should avoid contacting (for whatever reason).
  2. The CV should ask for a risk assessment of any patient before agreeing to meet them in a quiet room or other unobserved space. Volunteers are not obliged to carry personal alarms, but may always do so, and should carry one if advised to do so by ward staff.
  3. The CV will explain to patients that they are part of the ward team, and that they cannot and will not keep confidential anything which should be communicated to the ward team. If the patient asks for clarification, an explanation such as this may be offered: “whilst you are a patient here, your safety and well being are the responsibility of the NHS; if you tell me something that indicates you or somebody else is at risk, then I will need to pass this on to nursing staff.”
  4. On leaving the ward, or immediately after any contact that causes concerns, the CV will give a member of nursing staff a brief account of which patients they have seen and any concerns that may have arisen. The nurse will enter into the patient record any significant contacts, and record any concerns raised.
  5. If the CV is concerned that a contact needs to be recorded in more detail because it contains significant disclosures by the patient, or because the spiritual needs of the patient are complex, then the CV may either: a) ask for a member of the nursing team to join them and the patient for a 3 way meeting, which the nurse will record in the care record, or b) complete the form in Appendix 1 and ask for it to be inserted into the care record by a member of staff. Note: this form must be signed by the patient. It is not a vehicle for raising concerns that the CV may have, which are not shared by the patient.
  6. The CV must not leave the ward without reporting to nursing staff whom they have seen and any concerns that they have.
  7. CVs will keep a record of the number of patients that they have contact with for audit purposes. They should not take any aide memoires (e.g notebooks) out of the building, but must have secure storage in the unit that they visit.
  8. CVs need to communicate verbally with contracted chaplains so that there is neither duplication nor confusion. This communication should always be secure and confidential. It must not be by email unless some form of encryption/security is used. This communication does not replace the communication (outlined above) with ward staff who have the responsibility for the care and safety of patients.

Community service users

Chaplains are increasingly being asked to assess and/or support service users in the community. Their particular contribution is around complex religious, spiritual or cultural situations. They may see service users in Trust premises or at home or in the premises of partner organisations.

Chaplains have access to ECPA care plans after attending the appropriate training. The ECPA holds the total patient record, and chaplains’ contribution needs to be available to care co-ordinators.

  1. Chaplains will only offer regular contacts to new community patients after a referral from their care coordinator or after the approval of the care coordinator. With existing community patients, the chaplain will inform care coordinators of previous work and ask to be admitted to the list of staff allowed access to their ECPA.
  2. Chaplains will explain to service users at their first meeting that they are part of the Trust multi disciplinary team, and that they will enter case notes after each contact. The chaplain will not accept any information in confidence (beyond the normal confidentiality within NHS services).
  3. After every visit/contact, the chaplain will enter a case note in ECPA within 24 hrs. The case note will record relevant information. The case note will be labelled “Chaplain contact”. The case note will describe the chaplain’s work with the client on that contact. The chaplain may also record other details which may be relevant to the multi disciplinary team, but are not central to the chaplain’s role.

Example

  1. If a contact with a community patient causes concerns for the safety or well being of the patient or somebody else, the chaplain will contact the care coordinator (or leave a message with their team) immediately. The chaplain cannot perform a risk assessment, only alert the appropriate person within the multi disciplinary team.
  2. Chaplains should not keep notes that are not part of the care plan/ECPA. If the chaplain uses any aide memoires or prints out any part of the ECPA, these should be destroyed as soon as possible.
  3. If the chaplain keeps a manual record of appointments, phone numbers or addresses, these should be password protected or otherwise anonymised.
  4. When visiting patients in their own home or away from Trust premises, then the lone worker policy must be observed. Each chaplain needs to identify a Trust employee who will act as a security back up.

Day hospitals/drop in centres

Chaplains may meet service users less formally than by appointment. It will not be necessary to enter on ECPA every contact, if there was no development or change of significance. If the chaplain believes that a contact merits entry on ECPA then s/he should do so. If the chaplain has any concerns, these should be discussed with nursing staff in the venue or directly with the care coordinator.

5. Development, consultation.

Adopted after Chaplaincy team meeting on 1 November 2010. Consulted with senior nurse practitioner. To be ratified by PPF.

6. Equality.

This protocol raises no Human Rights concerns.It is an internal procedure that does not differentiate between any groups or service users. It was decided that a full EIA was not necessary.

7. Monitoring compliance.

The lead chaplain will oversee all chaplains’ contributions to care records. Local chaplains will oversee training of volunteers, and any additional records that volunteers may offer. Modern matrons and care co-ordinators may refer any concerns to the lead chaplain. Records will be subject to the usual audit processes of the units or care records.

8. Dissemination.

The protocol will be held by the lead chaplain, and distributed to all chaplains and volunteers electronically or in hard copy. It will be posted on the intranet, and disseminated to Matrons and Community Team leaders by email and via personal visits to team meetings.

9. References and Bibliography.

Trust Policies

Data Protection, Security and Confidentiality

Information Governance Policy

Information Sharing Protocol

Management of Health & Social Care Records

10. Appendix:

Template for Chaplaincy Volunteer’s addition to care Record.

Appendix 1

Chaplaincy note to be added to the care record.

Name:

Ward:Date:Time:

This patient has asked for the following notes to be added to their care record following a meeting with a chaplaincy volunteer:

Patient signature:Date:

Chaplaincy Volunteer name (print):

(If staff members wish for any information about this note, please contact Richard Harlow, Chaplain, mob: 07789272508)