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Interpreter Policy

The University of California, San Diego Health serves a significant population of Limited English Proficient (LEP) patients and their families. In order to provide quality patient care to patients who are LEP, hearing and/or sight impaired, it is essential that patients can effectively provide hospital staff with a clear statement of their medical condition and medical history, and understand the provider’s assessment of their medical condition, discharge instructions, medications, and treatment options. Interpretation services are available 24 hours per day. Services may include in person interpreter services, telephone interpreters, Video Remote Interpretation (VRI), and TDD/TTY.


UCSDH MCP 301.8, “Patients’ Rights and Responsibilities”
UCSDH MCP 339.1, “Consent for Anesthesia, Surgery, Special Diagnostic, or Therapeutic
UCSDH MCP 524.2, “Code of Organizational Ethics”

    A.    ASL: American Sign Language. 

    B.    First Access Points: Admissions and/or Registration. 

    C.    Interpreter: A person who is fluent in English and a necessary second language, who can accurately speak, read, and readily interpret the meaning and/or intent of words and phrases in one language into the correspondingly appropriate terms in the necessary second language. 

    D.    Interpreting: The process of understanding and analyzing a spoken or signed message and re-expressing that message accurately and objectively in another language. 

    E.    TDD/TTY: A telecommunication device for the deaf/hard of hearing. Electronic devices that include text communication via a telephone, or Video Remote Interpretation that is designed for use by persons with hearing or speech difficulties. 

    F.     Translation: The conversion of text written in one language to written text in a different language. 

    G.    Significant Healthcare Services/Information: Consents, explanations of new or complicated diagnosis, and quality/end of life issues.

    H.    Surrogate Decision Maker: The individual designated by the patient pursuant to an Advance Health Care Directive to act on his or her behalf in health matters in the event that the person loses decision-making capacity. A patient may revoke the designation of an agent either by a signed written statement or by personally informing the responsible physician. An oral designation shall be promptly recorded in the patient’s medical record. This oral designation is only valid for the duration of the patient’s hospital stay. 

    I.    Video Remote Interpretation (VRI): A form of remote interpreting that offers the delivery of interpreting services through videoconferencing technology. 

    A. UC San Diego Health (UCSDH) provides interpreting services as needed or requested for all patients or persons authorized to act on behalf of a patient. Services are offered at no charge 24 hours/day.

    A. The available sources of Interpreting Services are:

    i.    Staff Interpreters: The UCSDH Interpreting Services Office employs certified on- site medical interpreters qualified to provide Spanish interpretations. Services are available Monday – Friday, 8:00 am to 4:30 pm. On-site interpreters may be contacted by dialing the hospital operator. If the interpreter is not available in a timely manner, staff should use the Language Phone or the Video Remote Interpreter (Martti).

    ii.    Contracted Interpreting Vendors: Outside vendors that provide interpreter services when interpretations cannot be performed by the on-site interpreters. 
To schedule an agency interpreter, call UCSDH Interpreter Services. Schedulers should call Interpreter Services at the time the patient schedules an appointment. 

    iii.    Telephone Interpretations: Qualified telephone interpretations are available via the Language Phone. To facilitate telephonic interpretation, use the blue dual handset or cordless telephone. An Interpreter may be accessed by dialing the hospital operator and requesting an interpreter, or by dialing 171. If the clinic site does not have access to the speed dial (171) Interpreter Service, the hospital operator will assist in connecting the call. 

    iv.    Certified Sign Language Interpretations: Martti will be used by Deaf/Hard of Hearing patients. In the event it is determined that an on-site ASL interpreter is needed, scheduling and cancelling of on-site sign language interpreters requires a minimum advance notice of 48 hours. 

    v.    Video Remote Interpretation (VRI): Remote interpretations are available through the Video Remote Interpreter Monitors (Martti).

    vi. After business hours and on weekends, the Language Phone and Martti are available.

    B.    Language Interpreter Service availability notices [Form D978] will be posted in clinic and hospital locations advising patients and their families of the availability of interpreters. 

    C.    Staff may refer to attachment A to determine the Method of Interpretation for particular encounters. 

    D.    For consents, explanations of new or complicated diagnoses, and quality/end of life issues, interpreters should be used in the following order of availability: 1) In person interpreters, 2) Video Remote Interpreters, or 3) Language Phone Interpreters. 

    E.    The first access point in which a patient acquires services at UCSDH will determine the language needs of the patient. The patient’s designated language will be noted on the Face Sheet. The designated language need will also populate the Patient Admission Data Base (PADB). 

    F.    Use of Staff, Family Members, Friends or Surrogates as Interpreters is discouraged.

    i.    When the patient is scheduling an appointment, the department/clinic should not request or suggest that the patient bring friends or relatives to serve as an interpreter. 

    ii.    While UCSDH recognizes the patient’s right to request family member assistance, family members and friends should not be used to interpret significant healthcare services/information (diagnosis, consent, prognosis, treatment plan, etc.) unless a certified interpreter is also present in-person, by telephone or videoconferencing to verify the conveyed information. In instances where significant healthcare services/information is discussed, staff should request a certified Interpreter. 

    G.    A non-certified staff or family member may assist with providing limited, simple interpreting/translation services or in emergency situations when an interpreter is not immediately available to provide appropriate language assistance in person or over the telephone. The name of the non-certified family member used as an interpreter as well as the patient’s permission to have family/friend interpret should be documented in the patient’s health record. Family (at the patient’s request), may interpret simple patient instructions, make appointments, register and verify insurance.

   H.    The provider making use of an interpreter service will document the encounter in the patient’s electronic health record and include the date, time and source of the interpretation (e.g., on-site, telephonic, video, agency interpreter), interpreter name or ID #, language, and when appropriate, relationship to patient, and whether patient refused the use of a certified interpreter. 

    I.    Vital documents that are not in the primary language will be interpreted to the patient or surrogate decision-maker; the provision of oral translation of vital documents or information to patients will be documented in the patient’s health record. 

    J.    This MCP will be updated on an annual basis. 

    K.    A copy will be provided annually in December to the CDPH. 


Attachment A: Language Needs Guidelines


Form D978




--The Joint Commission (TJC)

--California Health & Safety Code, 1259, Chapter 672; Senate Bill 1840;


This policy and procedure was approved by the following committee(s):

Nurse Executive Committee | Date Approved: January 15, 2016

Medical Staff Executive Committee | Date Approved: February 18, 2016

Health System Executive Governing Body | Date Approved: March 1, 2016