One day recently I was at my desk entering documentation of patient visits.  One of my friends from the Information Technology Department came to my desk and said I was just the person he needed to see.  I asked him, “So did you visit me because you felt like receiving a prayer today?”  He smiled and said no he had a question about our records of patient visits.  He had been asked by a manager in our institution to determine how many patients receive pastoral care visits and how many patients have a visit attempted but the visit does not actually take place.  (Reasons for attempts to visit to not succeed are cases where the patient is with another staff member, the patient is having a procedure conducted in their in their room, or the patient is not in their room – which generally means they are having a diagnostic test in another location inside the hospital.)

I had him watch me enter several patient encounters and explained why some fields were not completed because the context of the visit.  In his concern about identifying visits where I end up not seeing the patient I showed him that we have two fields for interventions.  If neither field is completed then we were not able to engage with the patient for any visitor who was there for the patient.  He told me had been reading some of  my entries on his own and was confused about the fact that more fields have entries in one visit than they do in another.  He said by watching me describe the visit and let him know why I documented the visit the way I did, he saw much more clearly how what is documented captures the essential elements of the visit.  I thanked him for taking the time to not just see what I enter, but learn why visits are entered differently based on the unique dynamics of the visit.

As I reflected on the encounter throughout the day I realized I was glad that all the entries I make are being used by others in our system.  Documenting can take several hours of time each day and I now approach documenting with an increased sense of value because I have seen the data be used rather than just being stored.  Plus it was wonderful to be able to explain why I do what I do, and see the person interviewing me take the time to understand the reasons behind what I do.