Questions to Ask for Identifying Communication and Accommodation Needs

Patient or designated support person’s answers these questions.

These questions help determine patients’ access needs including communication access. These questions can be customized for use in the patient registration and appointment setting process as well as the in-patient nursing assessment process.

PATIENT:

I understand spoken information best when it is in _______________ [language].

I understand written information best when it is in _______________ [language].

Do you need assistance with? [√ checked boxes should lead interviewer to appropriate questions (or drop-down menus in a computer system) detailed below]

•  reading

•  walking

•  speaking

•  hearing

•  seeing

•  moving (mobility / physical / motor)

•  remembering, understanding, learning, communicating

1. MOVING (MOBILITY / PHYSICAL / MOTOR – LIMITED OR NO ABILITY GRAB, GRIP, LIFT, HOLD, ETC)

1.1. Uses

• Wheelchair

• Scooter

• Walker         

• Cane

• Braces

• Prosthesis

• Service Animal

  • - Overnight stay w/ animal

  • - Overnight stay w/o animal

• Stretcher

• O2

• Ventilator               

1.2. Needs                 

• Assistance walking

• Assistance transferring

• Assistance with positioning

• Accessible Sleeping  Room / bathroom*

  • Visual notification devices  (Door flasher)

1.3. Accessible medical equipment

• Scale

• Exam / diagnostic table or chair

• Assistance transferring

  • Full

  • Partial

  • Lift equipment

• Bariatric

  • Bed

  • Wheelchair

  • Lift equipment

• Other: (i.e. infusion chair, MRI etc )

Call Buttons / TV remote control / Water*

• Large button / pillow switches

• Sip / puff

• Accessible water source

*Inpatient only

2. HEARING

Interpreter [specify type]

• American Sign Language (ASL)

• Pidgin Signed English (PSE)

• Signed English

• Oral

• Cued speech

• Tactile

• Other. Explain:

Other accommodations:

• Letter, word, picture, translator boards

• Pad / pen – writing notes

• Visual notification devices *

  • door flasher

  • phone ring flasher 

• Phone with amplified sound *

• Computer-assisted real time transcription (CART)

• Assistive listening device

*Inpatient only

3. SPEAKING

Uses:

• Letter, word, picture, translator boards

• Speech Generating Device

4. UNDERSTANDING, REMEMBERING, LEARNING, COMMUNICATING

Difficulty with:

• Thinking of right words

• Putting thoughts together

• Following directions

• Speaking clearly

• Patient will need a family member/assistant for overnight stays

5. ACCESS TO PRINT MATERIALS:

• Large print (specify font size _____)

• Electronic text/disk/CD-ROM/Flash drive

• Audio Recording (CD, MP3, tape)

• Braille

• Qualified note taker

• Qualified Reader

  • Completing forms

6. TO USE THE PHONE I WILL NEED:*

• TTY

• Cordless

• Large buttons

• Speaker phone   - hands free phone

• Speed dialing

• Amplified volume and loud ringer

• Flashing light device (indicates telephone is ringing)

• Other:

*Inpatient only

7. MISCELLANEOUS:

• Longer appointment

  • Reason:

• Dietary*                           

  • Specify:

• Ask if there are any additional needs that may affect her/his care.*

*Inpatient only

PREFERRED COMMUNICATION: IDENTIFIES METHODS BY WHICH PATIENTS WANT TO RECEIVE COMMUNICATIONS AND INFORMATION:

8. PREFERS TO RECEIVE INFORMATION REGARDING APPOINTMENTS, TEST RESULTS, ETC

• USPS mail

• Email

• Voice mail

9. WHEN TRYING TO REACH ME IT IS BEST TO USE: [CHECK ALL THAT APPLY]

• Email (address: _______________)

• Text message (phone #: ___________)

• TTY

• Video relay

• Speech to Speech relay

• Phone

• USPS mail [if not time sensitive]

10. I UNDERSTAND / LEARN / GET DIRECTIONS/ BEST WHEN I GET INFORMATION: [check all that apply]

• In pictures

• In writing

• Explained to me

• Shown to me

11. WHEN VIEWING FILMS AND VIDEOS I NEED:

• Descriptive narration

• Captioning

• Signed