Documenting Compliance with the Use of Interpreter Services 

Communicating effectively with patients is an essential patient rights requirement and a key element in helping patients to fully receive care. Healthcare organizations may have staff onsite who are deemed competent to interpret for patients in a manner that meets the patient’s individual needs. Organizations may also contract with companies that provide in-person and virtual interpreter services. During consultations, we often observe that interpreters are used, but the interpretation is not consistently documented. No matter the interpretation method, it is crucial to ensure the documentation of interpretation in the delivery of care.

Considerations Include:  

  • With electronic medical records, does your system include a convenient notation for staff to indicate the use of an interpreter? We have seen pop-up screens that prompt staff to click the type of interpreter used and checkboxes at the beginning of an entry for documentation of the interpreter service.  
  • With paper medical records, do your forms include checkboxes for ease and reminder of documentation?  
  • How does your organization document patient refusal of interpreter services? Would patients be routinely reassessed for the use of interpreter services during their hospitalization?  
  • How does your organization audit compliance and ensure that not only the languages needed are provided but also dialects as needed? How does your organization document that speech, hearing, vision, and cognitive impairments are provided for?  

Providing information and communicating effectively in ways to meet individual patient needs are essential for the quality and safety of care. Avoid an adverse event and compliance issue by tracing the care of a patient’s communication needs to assess how effectively your processes meet requirements.  

Please contact us for questions or more information at  704-573-4535 or

Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 29 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.

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