The development of an outcome oriented and research informed spiritual care assessment and documentation form for the electronic health record in an adult hospital setting.

Standards for professional chaplaincy expect chaplains to document their work in patients' medical records, but no agreed upon standard for the content or format of such documentation exists. With the adoption of Electronic Health Records (EHRs) in many hospitals, chaplains may utilize a provided electronic form or one that can be customized from a basic format to departmental specifications. Ideally, the documentation form supports and reflects the work of chaplains in their specific clinical context.