Hospice assessment

PFCB-ChartAbstractionChecklist-PsychosocialSpiritualAssessment.doc

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Chart Abstraction Checklist—Psychosocial-Spiritual Assessment

Instructions for Use

This checklist can be used in three ways:

· Self-Assessment. Fellows can perform their own chart reviews. The fellow can then make a self-assessment, which he or she would share with a faculty mentor or program director.

· Peer Assessment. Fellows can use it to assess peers’ charts. In the presence of a faculty member or program director, the fellow would give feedback to the peer. This would allow practice of giving feedback and allow the fellow to learn from a peer’s documentation strengths and deficiencies.

· Faculty Assessment. Faculty can perform periodic chart reviews on fellows’ charts. The checklist would be reviewed with the fellow periodically in order to provide feedback on documentation, plans of care, etc.

Instructions for Entering Data

By Hand

Print the assessment tool and fill it out.

On the Computer

· Text—type the text (eg, fellow’s name) in the shaded area, then press the Tab key to move to the next field.

· Checkbox—click in the box or press the spacebar to select it.

· Saving—Select File, Save As, and save with a new name.

· Editing—If you want to make changes to the assessment tool, you must first unlock it so that it is no longer a form. To display the Forms toolbar in Word 2003, from the menu select View, Toolbars, Forms. Click the Protect Form icon to unlock it. Be sure to lock the form again after you have made the edits.

Chart Abstraction Checklist—Psychosocial-Spiritual Assessment
Competency Domain: Patient and Family Care, Practice-Based Learning and Improvement
Purpose: To assess fellow’s documentation of psychosocial-spiritual issues in the medical chart.
Instructions 1. Select 5 to 10 inpatient or outpatient charts. Criteria for patient chart selection: · Fellow completed a full assessment on this patient, either on admission, consultation, or on an outpatient visit. · Patient was cognitively intact and able to give a reliable history. 2. Review fellow notes for the items listed below.
Psychiatric History (Documented?)	Yes	No	Partial
1.	History or absence of previous depression	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
2.	History or absence of previous anxiety disorder	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
3.	History or absence of other psychiatric illness(es)	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
4.	History of substance abuse	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
5.	Current depression (if yes, presence of suicidal ideation?)	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
6.	Current anxiety	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
7.	Current coping	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
Social History (Documented?)	Yes	No	Partial
1.	Marital or partnered status	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
2.	Occupation or educational level	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
3.	Children	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
4.	Support system	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
5.	Financial issues	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
6.	Family coping	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
Health Habits History (Documented?)	Yes	No	Partial
1.	Current substance use or abuse	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
2.	Utilization of complementary therapies	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
Spiritual/Existential History (Documented?)	Yes	No	Partial
1.	Spiritual/existential/faith background	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
2.	Whether this is a source of support	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
3.	Current desire for chaplaincy or spiritual support	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
Assessment & Plan (If none identified, adjust scoring)	Yes	No	Partial
1.	Issues for follow up or treatments addressed	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
2.	Utilization of other resources: eg, social worker and/or chaplain consulted, psychiatric referral recommended, etc.	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
3.	Any issues of substance abuse addressed, if identified	FORMCHECKBOX	FORMCHECKBOX	FORMCHECKBOX
Scoring: 1 point for each item marked YES; and 0.5 point for PARTIAL Total Score:
16–21 = Excellent FORMCHECKBOX	11–15 = Good FORMCHECKBOX	6–10 = Fair FORMCHECKBOX	1–5 = Poor FORMCHECKBOX
3. Review results with fellow.
Date:	Fellow Signature:	Reviewer Signature:

Revised 10/1/2009. Adapted with permission from Rodney Tucker, MD, for the University of Alabama–Birmingham Center for Palliative Care, by the HPM Competencies Phase 3 Workgroup (Susan Block, MD; Laura Morrison, MD; Robert Arnold, MD; J. Andrew Billings, MD; Elise Carey, MD; Eva Chittenden, MD; VJ Periyakoil, MD; Sandra Sanchez-Reilly, MD; Rodney Tucker, MD) with funding from the Arthur Vining Davis Foundation and the Milbank Foundation for Rehabilitation. ©2010 University of Alabama–Birmingham Center for Palliative Care. All rights reserved.