This form can help you deal with a culturally diverse resident population.
Cultural Assessment
Name: _____________________________________________ Room:_____________
How would you like to be addressed by staff? _______________________________________________
Patient/Resident Interview: If impossible to interview patient/resident ask family representative these questions. (If using interpreter see reverse side before beginning interview)
Place of Birth ________________________ Number of Years in This Country____________________
Ethnic Affiliation ______________________________________________________________________
Primary Language _____________________ Secondary Language ____________________________
Able to read the following languages ______________________________________________________
Do you consider yourself a spiritual person?____ If yes, explain. ________________________________
____________________________________________________________________________________
Daily Prayer Needs ____________________________________________________________________
Food Preferences ______________________________________________________________________
Food Prohibitions ______________________________________________________________________
Home or folk practices done on a daily basis ________________________________________________
____________________________________________________________________________________
Preference for gender of caregiver? Female _________Male __________ Either __________________
What home remedies, care practices have you tried? __________________________________________
What herbal medications do you use? ______________________________________________________
Who are your support people? List : Family members _________________________________________
Friends _______________________________ Spokesperson __________________________________
It is important to understand the patient's/resident's perception of their illness, cause, and care. Have them explain in their own words what they feel is wrong.
Symptoms ___________________________________________________________________________
Cause ______________________________________________________________________________
How would you care for this condition in your home country? __________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Family Interview
Who will be making decisions for the patient/resident? _______________________________________
Do you want staff to let the patient/resident know their condition? ______________________________
Do you want us to discuss end of life issues with your relative? _________________________________
Objective Observation of Patient/Resident - Document what you see, hear or experience such as patient/resident dress, appearance, body posture, features, language, mannerisms, general behavior and attitudes.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Interpreter Use
If family members are used for interpreting, they may experience role conflicts and may lack needed medical vocabulary. They may withhold vital information in order to protect the patient/resident. In many cases, especially for sensitive medical and nursing issues, it is best to use a non-family or professionally trained interpreter when possible. When working with an interpreter, remember the following:
Working with an interpreter will take more time - patience is crucial
Explain the key issues to the interpreter before the session begins
Don't use long involved sentences
Use simple, straightforward language
Instruct the interpreter to translate the exact words of the patient/resident and not insert his/her own thoughts
Have the patient/resident repeat the question through the interpreter to be sure he/she understands
As a sign of respect, speak directly to the patient/resident and not the interpreter
Source: Illinois Council on Long Term Care. Used by permission.
