Use this SOP to provide respectful, effective, and understandable care that meets each patient's cultural, preferred-language, health-literacy, and communication needs. Besa Health team members must arrange qualified language assistance at no cost, communicate directly with the patient, protect privacy, document required information, and adapt communication for disability-related needs.

📚 Resources Needed

  • 24/7 qualified interpreter-service access information

  • Qualified bilingual staff or interpreter resources

  • The patient's medical record and preferred-language documentation fields

  • Besa Health member-grievance procedure and forms

  • Accessible communication materials, including written, audio, large-print, and Braille formats

✅ Before You Start

  • Culturally and Linguistically Appropriate Services (CLAS) mandates are federal requirements for recipients of federal funds, and providers must be aware of these standards.

  • Although CLAS standards are primarily directed at health care organizations, individual providers are encouraged to use them to make their practices more culturally and linguistically accessible.

  • Integrate culturally and linguistically appropriate services throughout Besa Health and work in partnership with the communities being served.

  • Interpreter services must be available 24 hours a day, 7 days a week, at no charge to patients.

  • Interpreters and bilingual staff must be assessed and qualified for the language assistance they provide.

  • Providers and office staff must understand linguistic access and cultural awareness.

  • Patients may file a grievance or complaint when their linguistic needs are not met.

🚀 Tips & Tricks

  • Greet and speak to the patient first, even when an interpreter or companion is present.

  • Use the patient's stated name and pronouns, and do not make assumptions about identity, education, comprehension, or ability.

  • Use standard, plain language, short sentences, and one question at a time.

  • Confirm understanding instead of relying on nodding, agreement, or assumptions.

  • Ask before touching, guiding, or providing physical support.

📘 Instructions

Step 1: Identify And Document Communication Needs

  • Ask the patient for their preferred spoken and written language and document it in the medical record.

  • Ask whether the patient needs an interpreter, sign-language interpreter, accessible format, communication aid, or additional response time.

  • If the patient refuses interpreter services, document the refusal in the medical record.

  • Choose a private setting and protect the patient's confidential information throughout the encounter.

Step 2: Arrange Qualified Language Assistance

  • Provide qualified interpreter services 24/7 at no charge to the patient.

  • Use an interpreter or bilingual staff member who has been assessed and qualified for the language involved.

  • Discourage the use of friends, family members, other patients, or minors as interpreters unless the patient specifically requests that person.

  • Explain that friends or family may withhold information because of embarrassment, protection, or emotional involvement; may have their own agenda; and may not know medical vocabulary.

  • Explain that using a patient's child as an interpreter may disempower the parent and burden the child through role reversal.

Step 3: Work With An On Site Interpreter

  • Greet the patient first, not the interpreter.

  • Face and speak directly to the patient.

  • Speak at an even pace using relatively short sentences.

  • Use standard English and avoid medical terminology and jargon.

  • Ask one question at a time.

  • Do not interrupt the interpretation.

  • Do not assume the patient's education level; difficulty speaking English does not necessarily indicate a lack of education.

Step 4: Work With A Telephone Interpreter

  • Use the same patient-centered practices required for an on-site interpreter and remember that the telephone interpreter cannot see visual cues in the room.

  • When the interpreter joins, state your name and explain the type of call.

  • For example: "Hello interpreter, this is James. Mrs. Dominguez would like to schedule a new-patient appointment."

  • Allow the interpreter to introduce themselves briefly to the patient.

Step 5: Respect Transgender Patients

  • Treat transgender people with the same dignity and respect you expect for yourself.

  • Use the person's name whenever possible.

  • Do not assume gender identity. Ask, "Which pronouns do you use?" and "Do you have a chosen name I should use?"

  • Focus on excellent care and customer service, not questions asked only out of curiosity.

  • Do not ask about genital status unless it is relevant to the care or service being provided.

  • Never disclose a person's transgender identity to anyone who does not explicitly need the information to provide care or service.

Step 6: Communicate With Patients With Speech Impairments

  • Recognize that limited speech may occur with disability, age, hearing loss, cognitive difficulty, or language differences and may also affect understanding.

  • Do not raise your voice; a person with a speech disability may be able to hear you.

  • Repeat what the person tells you to confirm that you understood correctly.

  • Ask one question at a time and allow extra time for a response.

  • Pay attention to pointing, gestures, nods, sounds, eye gaze, and blinks.

  • If speech is difficult to understand, ask the person to repeat it as many times as needed, including three or four times. It is safer to acknowledge that you do not understand than to make an error.

Step 7: Assist Patients With Visual Impairments

  • Gain the person's attention by speaking first.

  • Ask whether guidance or support is needed, and obtain permission before touching the person.

  • Introduce yourself and explain your role.

  • Speak directly to the person.

  • In a group conversation, identify yourself and make clear who you are speaking to.

  • Use verbal responses instead of nods or head shakes.

  • Describe your actions aloud.

  • Tell the person when you move away or leave the room.

  • Do not assume that a person who is blind has no vision at all.

  • Provide information in an alternative or accessible format, such as audio, large print, or Braille.

Step 8: Communicate With Patients With Hearing Impairments

A patient may use hearing aids and active-listening strategies, but everyone involved must still make a strong effort to communicate successfully.

  • Speak normally, neither too quickly nor too slowly, and use short, simple sentences.

  • Do not exaggerate speech or lip movements.

  • If the patient uses sign language, arrange an interpreter.

  • Be prepared to write questions and answers, and allow the patient to write as needed.

  • Write down important health education, instructions, or other information for the patient.

  • Use adequate lighting because the patient may rely on lip reading, facial expressions, body language, and gestures.

  • Minimize background noise.

  • In group settings, choose a location where the patient can see everyone's face.

  • After each important point, ask whether the patient understood and, when needed, ask the patient to repeat the message or instructions back, especially when the patient is unaccompanied.

Step 9: Support Patients With Cognitive Impairments Or Mental Health Challenges

  • Provide information clearly, concisely, concretely, and simply.

  • If the patient does not understand, change the communication method and use common words and simple sentences.

  • Allow time for the patient to process the information and respond slowly or in their own way.

  • Confirm that the patient understands the message.

Step 10: Complete And Document The Encounter

  • Document the patient's preferred language in the medical record.

  • Document any refusal of interpreter services.

  • Document the qualified language or communication assistance used and any accessible materials provided.

  • Confirm understanding of important information and explain the right to file a grievance or complaint if linguistic needs are not met.

🛠 Troubleshooting

The Patient Requests A Friend Family Member Or Minor As Interpreter

Discourage the arrangement and explain the risks of withheld information, personal agendas, unfamiliarity with medical vocabulary, and role reversal for children. Continue to offer a qualified interpreter. Use the requested person only when specifically requested by the patient and consistent with applicable requirements.

The Telephone Interpreter Cannot Follow What Is Happening

Describe relevant visual cues, identify each speaker, explain the type of call, speak in short segments, and pause for interpretation.

The Team Cannot Understand A Patient With Limited Speech

Do not guess. Ask the patient to repeat the message, confirm your understanding aloud, allow extra time, and use gestures, writing, or another appropriate communication method.

The Patient Says Their Linguistic Needs Were Not Met

Address the immediate communication need, notify the appropriate supervisor or Compliance team, and provide the Besa Health grievance or complaint process.

✅ Completion Check

  • The patient's preferred language was identified and documented.

  • Qualified language assistance was available 24/7 and offered at no charge.

  • Any refusal of interpreter services was documented.

  • Friends, family members, other patients, and minors were discouraged as interpreters unless specifically requested by the patient.

  • The patient was addressed directly and treated respectfully.

  • Communication was adapted for the patient's cultural, linguistic, sensory, speech, cognitive, or mental-health needs.

  • Important instructions and the patient's understanding were confirmed.

  • The patient was informed of the grievance or complaint option when linguistic needs were not met.

References

Guidance: HHS National CLAS Standards • CalOptima Referenced CLAS Standards Fact Sheet

Source: CalOptima Provider FSR/MRR Binder, pages 139-141 • Revised Apr 20, 2026