Charting and Documenting Spiritual Care in Health Services: Victoria, Australia

Abstract

Documentation in medical records is an important aspect of providing care in Australian healthcare services. Documenting spiritual care has evolved over many decades. A brief historical overview of the models of chaplaincy in Victoria, Australia, from the 1950s shows the development from faith-based models to more professional models over the last two decades. Models may include spiritual care faith representatives and volunteers, and access to medical records differs for each of these providers. The collection of data and the description of pastoral interventions in an Allied Health project at Austin Health, Heidelberg, Victoria, in the 1990s were a key milestone, as was the inclusion of pastoral care intervention codes in the Australian ICD-10_AM/ACHI/ACS codes in 2002. Reporting on spiritual care activity to the Victorian government’s Department of Health and Human Services emphasised this requirement to develop a minimum dataset and to educate the spiritual care sector. Three case studies of Victorian hospitals illustrate how documenting in electronic and paper medical records currently meets the Spiritual Health Victoria guidelines. Documentation assists with the integration of spiritual care in the health service, with internal reporting and with research. It also enables spiritual care activity to be visible and available electronically for reporting to government as required.