Patient Centered Communication
Changes are underlined.
Effective January 2012.
Standards.
• Human Resources: HR.01.02.01, EP 1
• Provision of Care: PC.02.01.21, EPs 1 and 2
• Record of Care: RC.02.01.01, EPs 1 and 28
• Rights and Responsibilities: RI.01.01.01 EPs 28 and 29, RI.01.01.03 EPs 2 and 3
HR.01.02.01 : The hospital defines staff qualifications.
1 A The hospital defines staff qualifications specific to their job responsibilities.
(See also IC.01.01.01, EP 3 and RI.01.01.03, EP 2)
Note 1: Qualifications for infection control may be met through ongoing education, training, experience, and/or certification (such as that offered by the Certification Board for Infection Control).
Note 2: Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), under Subpart M: “Personnel for Nonwaived Testing” §493.1351-§493.1495. A complete description of the requirement is located at http://wwwn.cdc.gov/clia/regs/toc.aspx.
Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists (as defined in 42 CFR 484.4) provide physical therapy, occupational therapy, speech-language pathology, or audiology services, if these services are provided by the hospital.
Note 1: Qualifications for infection control may be met through ongoing education, training, experience, and/or certification (such as that offered by the Certification Board for Infection Control).
Note 2: Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), under Subpart M: “Personnel for Nonwaived Testing” §493.1351-§493.1495. A complete description of the requirement is located at http://wwwn.cdc.gov/clia/regs/toc.aspx.
Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists (as defined in 42 CFR 484.4) provide physical therapy, occupational therapy, speech-language pathology, or audiology services, if these services are provided by the hospital.
Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964. (Inclusion of these qualifications will not affect the accreditation decision at this time.)
PC.02.01.21 : The hospital effectively communicates with patients when providing care, treatment, and services.
1 A The hospital identifies the patient's oral and written communication needs, including the patient's preferred language for discussing health care. (See also RC.02.01.01, EP 1)
Note 1: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials.
2 A The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient's oral and written communication needs. (See also RI.01.01.03, EPs 1-3)
1 A The hospital identifies the patient's oral and written communication needs, including the patient's preferred language for discussing health care. (See also RC.02.01.01, EP 1)
Note 1: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials.
2 A The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient's oral and written communication needs. (See also RI.01.01.03, EPs 1-3)
RC.02.01.01 : The medical record contains information that reflects the patient's care, treatment, and services.
1 C M The medical record contains the following demographic information:
- The patient's name, address, and date of birth, and the name of any legally authorized representative
- The patient’s sex
- The legal status of any patient receiving behavioral health care services
- The patient's communication needs, including preferred language for discussing health care (See also PC.02.01.21, EP 1)
Note: If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the medical record.
- The patient's name, address, and date of birth, and the name of any legally authorized representative
- The patient’s sex
- The legal status of any patient receiving behavioral health care services
- The patient's communication needs, including preferred language for discussing health care (See also PC.02.01.21, EP 1)
Note: If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the medical record.
28 A The medical record contains the patient’s race and ethnicity.
RI.01.01.01 : The hospital respects, protects, and promotes patient rights.
28 A The hospital allows a family member, friend, or other individual to be present with the patient for emotional support during the course of stay.
Note 1: The hospital allows for the presence of a support individual of the patient’s choice, unless the individual’s presence infringes on others' rights, safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient's surrogate decision-maker or legally authorized representative. (For more information on surrogate or family involvement in patient care, treatment, and services, refer to RI.01.02.01, EPs 6-8.)
29 A The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.
Note 1: The hospital allows for the presence of a support individual of the patient’s choice, unless the individual’s presence infringes on others' rights, safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient's surrogate decision-maker or legally authorized representative. (For more information on surrogate or family involvement in patient care, treatment, and services, refer to RI.01.02.01, EPs 6-8.)
29 A The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.
RI.01.01.03 : The hospital respects the patient's right to receive information in a manner he or she understands.
2 C M /3 The hospital provides language interpreting and translation services.
(See also HR.01.02.01, EP 1; PC.02.01.21, EP 2; RI.01.01.01, EPs 2 and 5)
Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population.
Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population.
3 C M /3 The hospital provides information to the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient’s needs.
(See also PC.02.01.21, EP 2; RI.01.01.01, EPs 2 and 5)