Document
Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Spiritual Care
Hysio organises the client's own words, meaning, wishes, boundaries and follow-up agreements from the conversation, with as little personal data as possible.
A structured report in your professional terminology
From care encounter to report
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
Document
Record the conversation and clearly state your own findings and agreed actions.
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More attention for the conversation, less typing afterwards.
State relevant information, your own findings and agreed actions aloud so you can find them in your report.
The information appears under the headings of your chosen report format, so you can review each section.
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
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Quick answer
The four formats fit the conversation, the intake, the family or bereaved relatives conversation and the handover.
Conversation, intake, family conversation and handover each have a format of their own. Own words, sources, wishes, consent and boundaries stay visible without meaning being filled in.
This documentation format is for a conversation about meaning, sources, wishes and boundaries that the client expressed themselves. Preserve the client's own words and describe how you keep them apart from your interpretation of the conversation. In the spiritual care conversation report, keep the life story, meaning-making and professional interpretation of the conversation carefully separate. With voice-driven reporting, you dictate after the conversation what the client said in their own words; Hysio organises it and you choose what stays confidential. [2] [7] [3]
This documentation format is for a first conversation with a request for support, the client's own words, sources, wishes and confidentiality. Make the confidential context readable by recording how you name the request for support, the worldview source and the transparent connection separately. In the worldview intake, the spiritual caregiver decides what is necessary and appropriate to keep. [2] [8] [4]
This documentation format is for a conversation in which the client and loved ones have separate source roles. Write up the conversation with restraint: note how you place each speaker and their words recognisably side by side. In the family and bereaved relatives conversation, leave beliefs, rituals, doubts or wishes with the source that expressed them. [2] [9] [5]
This documentation format is for a handover with the necessary words of the client, wishes, consent and status. For careful follow-up, describe how you note the purpose, recipient, consent and sharing status separately. In the spiritual care handover, check consent, recipient and purpose of the information before anything is shared. This way the handover remains a factual continuation of what was already recorded earlier in the conversation and the intake, without adding new content. [2] [8] [6]
A first conversation about meaning-making calls for a worldview intake and not for a filled-in identity or conclusion. Keep the client's own words and describe how you organise the request for support and the client's own words as a starting point. In a first conversation about meaning-making, keep the life story, meaning-making and professional interpretation of the conversation carefully separate. [2] [9] [4]
A question about meaning is a client's word or conversation theme that needs context and the client's own wording. Make the confidential context readable by recording how you do not replace the question with a general worldview interpretation. [2] [7]
A worldview source can be a personal belief, tradition, text, ritual or experience when the client mentions it. Write up the conversation with restraint: note how you record the source only with the meaning the client gives it. For a worldview source, leave beliefs, rituals, doubts or wishes with the source that expressed them. [2] [12]
A client's wish is an expressed need, boundary or preference within the conversation, for example about presence, a ritual or the sharing of information. For careful follow-up, describe how you keep the wish, observation and your own interpretation apart. For a client's wish, check consent, recipient and purpose of the information before anything is shared. [2] [7]
A worldview identity belongs to the client's own words and consent and not to a plausible interpretation. Keep the client's own words and describe how you do not infer an identity from a name, background or subject. For a worldview identity, keep the life story, meaning-making and professional interpretation of the conversation carefully separate. [2] [12]
Confidentiality and boundaries are conversation topics that are only recorded when they have been discussed. Make the confidential context readable by recording how you do not merge agreement, wish and factual handover. [2] [8]
A conversation can touch on meaning, worldview, hope, guilt, saying goodbye, connectedness, fear or ritual when the client brings them up. Write up the conversation with restraint: note how you keep only the themes that were actually discussed and the client's own words. For themes in spiritual care, leave beliefs, rituals, doubts or wishes with the source that expressed them. [2] [9]
The client's voice is recognisable when words, wishes and nuances are not replaced by a professional summary. For careful follow-up, describe how you keep the core close to the wording of the source. [2] [7]
Meaning is what the client or loved one expresses themselves, while interpretation can be an additional reading by the healthcare professional. Keep the client's own words and describe how you note both layers and their source separately. For meaning and interpretation, keep the life story, meaning-making and professional interpretation of the conversation carefully separate. [2] [7]
A request for a ritual is a client's wish with practical, worldview and sometimes organisational context. Make the confidential context readable by recording how you do not expand the request with a ritual you made up yourself. [2] [8]
A conversation about saying goodbye can contain emotions, values, relationships and wishes without proving a fixed stage of grief. Write up the conversation with restraint: note how you organise the client's words and the follow-up without a grief label. For a conversation about saying goodbye, leave beliefs, rituals, doubts or wishes with the source that expressed them. [2] [9]
A loved one can bring in their own observation, wish or question that does not automatically reflect the client's view. For careful follow-up, describe how you note the client and the loved one with separate source roles. For a loved one as a source, check consent, recipient and purpose of the information before anything is shared. [2] [9]
A shared meaning is only a shared point in the conversation when those involved have recognisably expressed it together. Keep the client's own words and describe how you do not infer consensus from similar words. For shared meaning, keep the life story, meaning-making and professional interpretation of the conversation carefully separate. [2] [9]
A client's boundary can concern topic, presence, sharing or follow-up and calls for a clear source. Make the confidential context readable by recording how you note the boundary as a stated wish and not as your own judgement. [2] [7]
A referral is a discussed or chosen next step with a purpose, recipient and agreement when that is clear from the conversation. Write up the conversation with restraint: note how you keep the proposal, consent and carrying it out separate. For a referral, leave beliefs, rituals, doubts or wishes with the source that expressed them. [2] [9]
A silence is not automatically a meaning, emotion or agreement and only belongs in the report when it has been named as relevant. For careful follow-up, describe how you do not add a psychological interpretation to silence. [2] [8]
The VGVZ professional standard provides a professional context for spiritual care, the relationship and documentation. Keep the client's own words and describe how you use the standard as a framework and do not fill in a case conclusion. [2] [7]
The source on spiritual care and the medical record system emphasises a fitting, restrained choice of information and place. Make the confidential context readable by recording how you organise only the data needed for continuity. [2] [8]
The WGBO context (the Dutch Medical Treatment Contracts Act) concerns the record, access, consent and confidentiality in care relationships, including within spiritual care. Write up the conversation with restraint: note how you do not present general legal context as individual consent. Always compare the note on the record, access or consent with what was actually said in the conversation. [2] [11]
Sharing within a team requires a purpose, necessity, consent or legal basis and an appropriate recipient within the chain of care. For careful follow-up, describe how you note the purpose, recipient and sharing status separately. When sharing client information with a team, check consent, recipient and purpose of the information before anything is shared. [2] [10]
A data-minimal report in a medical record system contains only the information needed for the agreed continuity or accountability. Keep the client's own words and describe how you leave out details that have no clear function in the record. When you do your admin with AI, you still choose what remains of the conversation. [2] [8]
Consent is a separate status that is only mentioned when the source discusses or records it. Make the confidential context readable by recording how you do not infer consent from a friendly conversation. [2] [11]
A sharing boundary or wish for confidentiality is relevant information for the handover and can limit its content. Write up the conversation with restraint: note how you keep the boundary visible and do not pass on any detail anyway. [2] [7]
Collaboration can be a contact, question, shared topic or follow-up appointment without the spiritual caregiver giving a medical assessment. For careful follow-up, describe how you name roles and expressed actions separately. For collaboration with a practitioner, check consent, recipient and purpose of the information before anything is shared. [2] [9]
Continuity requires the necessary words of the client, wishes, boundaries and status of the follow-up for whoever takes over the conversation. Keep the client's own words and describe how you only pass on details with a clear function. [2] [8] [6]
A request from family is a separate source and does not automatically say what the client wants or allows. Make the confidential context readable by recording how you note the family's question, the client's wish and consent separately. [2] [9]
The Palliaweb guideline provides context for meaning-making, spirituality, reporting and referral in palliative care. Write up the conversation with restraint: note how you do not use the guideline as a personal interpretation of the client. [2] [9]
The zib Levensovertuiging (the Dutch health and care information building block for beliefs) offers an information model for worldview data and does not replace a conversation with the client. For careful follow-up, describe how you keep the source and the client's own words visible together. [2] [12]
A source is a spoken word, document or observation, while an interpretation can be an explicit professional reading. Keep the client's own words and describe how you note both separately with their origin. For source and interpretation, keep the life story, meaning-making and professional interpretation of the conversation carefully separate. [2] [7]
A religious text that is mentioned is a source item whose meaning and relevance stay with the client. Make the confidential context readable by recording how you do not give the text a meaning of your own. [2] [12]
A stage of grief must not be inferred from behaviour or subject without the source explicitly supporting it. Write up the conversation with restraint: note how you describe the experience without a grief label. [2] [9]
For careful follow-up, describe how you record the status only on the basis of the source, for example sent, received or still pending with the receiving healthcare professional. For a handover status, check consent, recipient and purpose of the information before anything is shared, and only update the status once that has actually been confirmed. [2] [8] [6]
Personal details do not automatically belong in the medical record system when they have no clear function for continuity or accountability. Keep the client's own words and describe how you assess necessity and purpose before inclusion. [2] [8]
A spiritual need belongs to what the client names themselves and cannot be inferred from silence, background or diagnosis. Make the confidential context readable by recording how you describe the need only as a source item. [2] [10]
A warm text stays precise when the client's own words, the source, boundaries and follow-up remain recognisable. Write up the conversation with restraint: note how you use human language without adding new meaning. [2] [7]
Hysio organises source information but does not make a diagnosis, does not interpret grief and does not determine any religious or worldview meaning. For careful follow-up, describe how you leave the spiritual caregiver as the deciding source. [2] [11]
For spiritual care, Hysio Starter costs €20 per month excl. VAT. The rate belongs to the plan and not to one profession or documentation format for spiritual care. Pro and Unlimited offer the same access with higher monthly use. The spiritual caregiver remains responsible for checking and finally saving every note. [13]
Spiritual care is listed as a fixed profession in the Hysio catalogue, with its own route, name and four named documentation formats for the conversation report, intake, family conversation and handover. You can see in the platform itself which documentation formats are visible and usable for your own practice. The spiritual caregiver therefore always assesses the source information, professional content, missing details and the final record text, with their own professional review, before it is used. [16]
You can try Hysio free for fourteen days before you choose. During that period you get to know Hysio; this page describes which documentation formats are intended for spiritual care. Use the trial period to look at Hysio, and always assess the outcome against the conversation. The spiritual caregiver then chooses what is useful and checks the text against source, context, record purpose and professional agreements. [14]
In spiritual care, human review remains necessary for the origin of the source, professional content, missing information and the final choice for the record, even when the conversation has been fully dictated afterwards and organised automatically. Always compare the text against the original notes before you determine consent, recipient and purpose of the information for sharing it. [16]
For spiritual care, Hysio does not write directly to an electronic record; the spiritual caregiver assesses the text and transfers it themselves. Keep the client's own words and describe how you assess the text yourself and manually transfer it to the right place. [17]
For spiritual care, time can be saved by organising a conversation or dictation, but review and safe transfer remain part of the work. Make the confidential context readable by recording how you take time for source review and data-minimal transfer into account. [2] [7]
Assessment of the report structure centres on one clearly defined conversation and alignment with that conversation type. Compare the text with the original notes and keep only necessary information. Keep the client's words, the words of loved ones and the professional interpretation of the conversation apart. The spiritual caregiver decides what is appropriate to transfer. [16]
In spiritual care, Hysio does not fill in any missing measurement, consent, assessment, action or agreement, not even when a conversation seems to give reason to. For careful follow-up, describe how you do not fill empty sections with meaningful assumptions. [2] [11]
Write down that the client asked for this and what it was about, without noting the content itself. That way you respect confidentiality and a colleague knows there is an agreement. You decide what does go into the medical record system. [16]
In spiritual care, the spiritual caregiver remains responsible for the choice of sources, professional assessment, correction and final saving. Make the confidential context readable by recording how you do not hand the final assessment over to the text. [16]
Hysio creates the report. You remain responsible for what you save in the record.