Advanced Effective Communication, Cultural Competence, and ...

Chapter Two
Assessment
After a patient is admitted to the hospital, clinical staff conduct a
clinical assessment to determine the care, treatment, and services
that will meet the patient’s needs. Staff should focus on
collecting any clinical, environmental, demographic, or social
information relevant to diagnose and treat the patient. Although
several basic patient needs should be identified during
admission, the assessment process provides an opportunity to
probe potentially sensitive issues more deeply. Many factors can
influence care and are important to consider. Some of these
include the patient’s health literacy, mobility, sexual orientation,
gender identity and expression, cultural, religious, spiritual,
lifestyle, or dietary needs.
This chapter highlights the importance of integrating effective
communication, cultural competence, and patient- and
family-centered care into the hospital’s system of clinical
patient assessment. The accuracy of assessment depends upon
the accuracy of the information received, making effective
patient–provider communication vitally important. Staff
must make sure to address the patient’s communication needs
before conducting a comprehensive assessment or engaging
the patient in care discussions.
The next section includes both recommended issues to
address during patient assessment (with check boxes) and
practice examples (with round bullets). While the
recommended issues present broad, overarching concepts that
all hospitals should address, the example practices and
methods may not apply to all hospital types, sizes, or settings.
✔ Checklist to Improve
Effective Communication,
Cultural Competence, and
Patient- and Family-Centered
Care During Assessment
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Identify and address patient
communication needs during
assessment.
Begin the patient–provider relationship
with an introduction.
Support the patient’s ability to understand
and act on health information.
Identify and address patient mobility
needs during assessment.
Identify patient cultural, religious, or
spiritual beliefs or practices that
influence care.
Identify patient dietary needs or
restrictions that affect care.
Ask the patient to identify a support
person.
Communicate information about unique
patient needs to the care team.
Recommended Issues and
Related Practice Examples to
Address During Assessment
❑ Identify and address patient
communication needs during
assessment.
Provide appropriate communication assistance during the
assessment process to meet the communication needs
previously identified during the admission process and
allow for accurate information exchange between the
patient and provider. Patient communication needs and
supports should be recorded in the patient’s medical
record, and any documented communication needs
should trigger staff to arrange for the appropriate
communication assistance.*
* See Chapter 6: Organization Readiness: Provision of Care, Treatment, and Services (page 40 and 41) for additional information on providing
language services, auxiliary aids, and augmentative and alternative communication resources.
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