Healthcare Health Ministry Note

HEALTHCARE HEALTH MINISTRY NOTE

Patient Information

Date of Birth:    Gender: Male Female Non-binary Decline to state

Insurance & Coverage

Medical & Spiritual History

Visit Details

Visit Date:    Visit Time:    Location:

Faith Tradition / Religious Affiliation:    Primary Language:    Interpreter Needed:

Assessment

Risk assessment: Suicidal ideation: Yes No    Homicidal ideation: Yes No

Advanced directives present:    Emergency contact notified:

Interventions & Plan

Staff Present:    Minister / Chaplain:

Title / Credentials:    Contact (internal):

Legal & Confidentiality Acknowledgment

This note documents spiritual care provided as part of the patient's health record. Information contained herein is confidential and will be handled in accordance with applicable federal and state privacy laws. Disclosures are limited to treatment, payment, and health care operations or as otherwise authorized by law or patient authorization.

By checking the box below, the patient (or legal representative) consents to inclusion of this health ministry note in the medical record and permits care team members to be informed of spiritual care interventions relevant to the patient's clinical care.

I consent to inclusion of this note in the medical record and information sharing as described above.

Authorization Expiration Date (if limited):    If no date entered, authorization remains part of the record in accordance with facility policy.

Capacity & Representative

Patient capacity for consenting to spiritual care was assessed: Yes No

If signed by legal representative, relationship to patient:

Staff Certification

I certify that the information recorded on this form is accurate to the best of my knowledge, that interventions were provided as documented, and that appropriate referrals and notifications were made as required by clinical judgment and facility policy.

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