As early as 1998, the American Society for Bioethics and the Humanities (ASBH), in Core Competencies for Health Care Ethics Consultation, makes the recommendation that ethics consultation should be documented in the patient’s record or some other permanent record. Over 20 years later, it is not uncommon to find health care institutions that struggle to determine whether and to what extent such documentation should occur. In response to this need, the authors compared clinical ethics consultation (CEC) templates from two different institutions for consideration in various phases of development: design and implementation, and utilization.

RATIONALE FOR STANDARDIZATION IN DOCUMENTATION
ASBH’s Core Competencies for Health Care Ethics Consultation and the Catholic Health Association’s Striving for Excellence in Ethics represent two significant resources within the field that inform the standards by which CEC is performed. The latter resource offers the following under the heading “Consultation & Advisement 3.d.”:

Guidelines for Ethics Consultation. 
The ethics consultation service operates according to established committee guidelines regarding documentation processes and standards.¹

The former resource offers the following in its 1998 edition:

Documentation. Ethics consultations should be documented either in the patient record, or in some other permanent record. The results of consultations ethically requiring patient involvement should be communicated to patients. All consultation services should have a policy specifying the degree and type of documentation required for consults. Such documentation promotes accountability, optimizes communication, and facilitates quality improvement.²

ASBH reinforced this standard again in the 2011 revision of the Core Competencies 
document, stating:

Documentation. All case consultations in which the patient’s participation is ethically relevant or that will have a material impact on the patient’s care should be documented in the patient’s medical record, except in rare circumstances ... Standard forms or standardized electronic data entry are useful for ensuring that all important components of ethics consultations are consistently and thoroughly summarized in the patient’s medical record.³

While the 2011 ASBH standards include both the normative claim regarding documentation in general, as well as offering suggested fields for consideration when creating a standardized documentation format, they do not fully explore “why” such documentation should be considered. From our perspective, the “why” can be found in how standardized documentation in the EMR is of benefit in the following three areas: 

Education

• Clarifies the essential elements of a quality ethics consultation chart note for 
  those reading the note
• Informs the ethics committee members and health care ethics consultants about the standards for clinical ethics consultation documentation

Communication

•  Anchors documentation of ethics consultation across care settings within 
  and beyond the patient’s current hospitalization or medical encounter
• Highlights the critical recommendations from a clinical ethics consultation in the patient’s EMR as a matter of transparency, consistency and efficiency

Quality

• Reduces the potential for unnecessary variability in approaches to documentation
• Provides data capture mechanisms for continuous quality improvement initiatives

EMR CEC TEMPLATES

Design and Implementation Phase
In the CHI Health – Midwest Division of CommonSpirit Health, a multi-site health care system employing a consultant model for ethics consultation, various opportunities for realizing the benefits of standardized template development prompted efforts to move towards standardization. While variability across individual consultants was minimal because of the limited number of people documenting consultations, designing and implementing a standardized template promised to be beneficial in that it could provide consistency across consultation events, as well as consistency in those instances where ethics consultations were documented by someone other than the primary consultant. Implementation of standardized templates held the possibility of creating efficiencies by providing a documentation framework that prompted for key elements within the consultation note, and of providing a communication shell that could be easily and more quickly completed. Finally, integration of the standardized documentation would allow for providers and other health care team members to become familiar with the content, purpose and substance of ethics consultations, allowing them to quickly locate the various elements of the consultation note, such as the resulting recommendations, the ethical analysis, or even the follow-up contact information.

To this end, our system developed a consultation documentation template for use within the EPIC platform. Designed around the already-familiar SBAR (Situation-Background- Analysis/assessment-Recommendation) format used within other interdisciplinary communication, this template includes elements that provide background information, such as who requested the consultation and how, the modality of the consultation, who all was involved, the ethical analysis, and the resulting recommendations. Efficiencies are gained by utilizing pre-population functions of the EMR for such things as name, age, demographics, admissions/length of stay (LOS) data and other key elements of the consultation note. Recommendations are clearly highlighted with bold font, and contact information is incorporated automatically to make follow-up communication easier should other team members want to connect back to the consultant. The standardized template also includes information about what topics of ethics consideration have been addressed within the consultation itself, with the latest iteration of the template incorporating the Armstrong Clinical Ethics Consultation Coding System 2013^©.* 

The standardized documentation template developed at CHI Health continues to be refined based on feedback from stakeholders and benchmarking with similar organizations. Opportunities for expansion of its use across CommonSpirit Health are being explored as well, as are opportunities or adaptation into other EMR platforms. 

One current positive outcome of the development and implementation of this standardized documentation template is the satisfaction of those using and referring to it. Benefits have already been realized in terms of the time efficiencies gained from the prompts regarding what to include. In addition, the various standardized elements help tell the story of the consultation in a way that brings as much clarity as possible to the often gray areas of ethics consultation, and that “speaks the language” of the EMR practices of other health care professionals.

Utilization Phase
In roles with both Ascension and with Hospital Sisters Health System (HSHS), design, implementation, and utilization of a CEC template for the EMR were relatively similar. In the case of this work within Ascension in 2015, unique challenges presented themselves with regard to the size and scale of such an initiative across seven EMR platforms. Within HSHS, the scope of the work was significantly reduced to a single platform.

Importantly, for the purposes of utilization, fields for documentation emerged that were consistent across both systems. These fields include:

• Requested Assistance
• Discipline Requesting
• Ethical Question, Inquiry or Concern Stated by Person Requesting Consult
• Patient Pertinent Clinical Information 
• Disciplines Engaged in Ethics Consultation 
• Applicable Ethics Policy Categories
• Patient’s Preference(s)
• Reason for Ethics Consultation
• Category for Ethics Consultation
• Summary of Ethical Analysis

Once the documentation was finalized, standardized date and time stamp to the record was integrated. 

It was important for EMR documentation to reflect the standardized methodology for case review. In this way, each category within the EMR template reinforced the essential elements of high-quality CEC. In both systems, the framework of Assess, Analyze, Act was used and served as the headers for the above fields.⁴ In nearly all fields open narrative was significantly limited in favor of drop-down menus. This served a number of purposes, most importantly, to minimize unnecessary and risk-associated variance in the patient’s medical record while creating opportunities for continuing quality improvement initiatives in CEC.

CONCLUSION
Two efforts at developing, implementing and utilizing a standardized documentation template are illustrated within the examples presented here. Though work in this area continues, already the benefits in terms of education, communication and quality have been realized. 

Several long-term opportunities remain, including evaluating if standardized templates demonstrate increased efficiency and consistency over time, and how they are perceived by non-consultants reading the information contained within the consultation notes. There are also opportunities to see how such templates can provide for increased data collection and quality analysis over time. Finally, there are cross-organizational opportunities for sharing templates and developing standards that are agreed upon and adopted across the field, for internal and external benchmarking, and for the development of common recommendation phrases that can further educate colleagues about the reasons for various recommendations in a way that reflects professional standards. Ultimately, the goal is for the story of the ethics consultation to be told within the medical record in a way that demonstrates quality, consistency and reflects the professional standards of the field. 

MARK REPENSHEK, PH.D.
Vice President
Ethics and Church Relations
Ascension
St. Louis
[email protected]

LESLIE KUHNEL, D.Be., HEC-C
Division Vice President
Ethics and Theology
CHI Health
Omaha, Neb.
[email protected]



ENDNOTES

1. Striving for Excellence in Ethics. https://www.chausa.org/publications/health-care-ethics-usa/archives/issues/fall-2010/striving-for-excellence-in-ethics. 
   Accessed 4 Feb. 2020.
2. “Core Competencies for Health Care Ethics Consultation.” https://repository.library.georgetown.edu/handle/10822/910657. Accessed 4 Feb. 2020.
3. “Core Competencies for Healthcare Ethics Consultation” http://apps.asbh.org/store/product-details?productId=95. Accessed 4 Feb. 2020.
4. Matthew Kenney, “A System Approach to Proactive Ethics Integration,” The National Catholic Bioethics Quarterly 10(1) (2018): 93-112.