Patients have the right to receive information in a manner that he or she understands.  This policy outlines tools to assure access and continuity of care related to healthcare information and services for patients with communication barriers.


In accordance with California’s Health and Safety Code, Section 1259 a determination of any communication barrier will be made upon registration or upon initial nursing assessment of the patient.

A patient has the right to determine who will provide interpreter services to him/her.  If the patient chooses, a family member or a friend may provide the service for non-critical services.  This determination must be made through either the telephone interpreting service or another non-hospital employed certified interpreter.  The patient’s choice will be documented in the patient’s medical record.  Family members under the age of 18 years will not be utilized for interpretive services.

Licensed professional healthcare practitioners and medical social workers (MSWs) that are bilingual may provide interpretation for non-critical services as needed to patients in their care if the patient agrees.

For all invasive procedures, issues involving domestic violence, sexually transmitted infections (STI), or other situations involving sensitive personal information or informed consent, a formal interpreter service will be utilized.  Formal interpreter services are the CyraCom Phone, Language People or a member of another authorized interpreter service.

When a patient care conference is needed, an authorized interpreter service will be obtained through Social Services or the Administrative Manager/Coordinator to provide services for the patient and the family.

Signs will be placed in conspicuous locations such as the emergency department, registration areas, the hospital main entrance, and outpatient departments advising patients and their families of the availability of interpreting services.

Standardized written materials including Patient Rights and the Notice of Privacy Practice that are available to patients upon admission and upon discharge will be reviewed on a regular basis to determine which should be translated in languages other than English.  Currently our geographic area meets the 5% requirement, Section 1259 of the Health and Safety Code, to have written materials translated in Spanish only.






All patients will have communication barrier(s) identified at the time of service by Patient Access or by Nursing Services. Communication barriers will be assessed upon admission and reassessed throughout the patient’s stay and results will be documented in the electronic medical record.

Language Resources
Telephone interpreting services will be available for interpretation 24 hours a day.  NorthBay Healthcare currently contracts with CyraCom for this service.

CyraCom Blue Phones are available on all inpatient units and throughout outpatient service areas.  Pick up the handset, push a button and say the language that needs to be accessed.  When using the service, NorthBay staff is required to document in the patient’s medical record the interpreter’s identification number and the content of information interpreted.

To identify the patient/family language and dialect, reference the CyraCom quick reference cards posted in common areas.  The telephone interpreting service will be able to assist with determining correct languages and dialects.

Hearing/Speaking Resources
Video Remote Interpreting (VRI) is available to patients with hearing impairments who require interpreting services.  A laptop with the needed software resides at each hospital campus and can be accessed by the social workers during day shift hours and by the Administrative Coordinators after hours.

NexTalk TTY services are available to patients by dialing the 800 number posted throughout the system.  This will connect the caller with a relay operator that will connect the caller to one of the designated computers throughout the system, in the hospital and in outpatient areas.

Visual Resources
For visually impaired patients, the healthcare staff will read materials to them, as appropriate, and/or, with the patient’s permission, will engage patient’s family and friends to participate in communication and education no differently than done with patients who have vision capabilities.

All communication involving interpreting services will be recorded in the patient’s electronic medical record.  Documentation will include the date, the time, the name of the agency, and an identifying name or number of the individual providing the interpretation.

Annual Review Responsibility
The Director of Case Management will be responsible to ensure the transmittal of the annual review of the policy to the California Department of Public Health.

The Director of Case Management will annually review posting of this policy on the NorthBay Healthcare website.

Effective Date: June 2016