Medical Interpretation Services Documentation Form in Patients’ Charts

In order to meet emerging regulatory guidelines regarding appropriate documentation of interpretation services in the medical record of patients with language needs, a new form has been developed.  Effective immediately, whenever an interpreter is used to communicate medical information to patients, whether in-person or telephonically, it should be denoted in the patient’s chart, using the Medical Interpretation Services Documentation Form.

This form is now available in the progress notes section of the patient’s chart. The blue color of the form should help with easy identification. When an in-person medical interpreter is present, he/she is responsible for completing the form.  When the telephone is used, the nurse/provider is responsible for completion of the form.  This template will be part of the WellStar Connect, (Epic®) system.

Providers should not use family members or minors to serve as medical interpreters.  While patients may request that family members or minors serve in this capacity, providers should always use a trained medical interpreter.  This will ensure that the information relayed to the patient is accurate and complete.  Often family members/friends do not have the language skills to convey medical information accurately or may not communicate the full extent of the information to the patient.  Use of a trained medical interpreter, in-person or telephonically, ensures that patients are fully informed and can better participate in decision-making and follow discharge instructions.

For more information about interpretation services at WellStar, please contact Stephanie Taylor, director, Cultural Competency at Stephanie.taylor@wellstar.org or 470-956-6419.