Chaplains’ Charting in the USA in the Era of “Open Notes:” Recommendations from a Quality Improvement Project

Hirschmann J, Terry K, Thyn RV, Strano A. Chaplains’ Charting in the USA in the Era of “Open Notes:” Recommendations from a Quality Improvement Project. Journal of Religion and Health. Published online August 23, 2025. doi:10.1007/s10943-025-02414-3‌Hirschmann J, Terry K, Thyn RV, Strano A. Chaplains’ Charting in the USA in the Era of “Open Notes:” Recommendations from a Quality Improvement Project. Journal of Religion and Health. Published online August 23, 2025. doi:10.1007/s10943-025-02414-3‌

https://doi.org/10.1007/s10943-025-02414-3 ‌

In the USA, the 21st Century CURES Act of 2016 requires healthcare providers to give patients online access to their electronic health records. This paper presents recommendations that arose from a three-stage quality improvement process concerning chaplains’ note-writing in the era of “open notes.” Recommendations included utilizing strengths-based language, avoiding linguistic structures that express disbelief, making notes more concise, and using their notes to continue their care of patients. For chaplains in outpatient oncology clinical settings, additional recommendations take into account the use of phone outreach and the longer-term nature of spiritual care relationships.