Psychosocial Spiritual Assessment Essay Project

Description/Paper Instructions

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