Nurses' Notes
1440: The nurse observes an admission interview with a client who has limited English proficiency. The chart shows that the client's preferred spoken and written language is documented in the admission record. At 1445, staff state that the client's minor child will interpret the medication history. The nurse obtains a qualified video interpreter, and the screen is positioned so the client can see both participants. The consent discussion begins, but a visiting neighbor is asked to explain the procedure and risks. During the interview, the clinician speaks only to the adult family member instead of addressing the client. The interpreter pauses after each short segment, and the client is given time to answer directly. The discharge packet is prepared, but vital medication warnings are provided only in English. The client asks for a spouse to remain present, and the requested support person stays with the client's permission. At 1500, the nurse uses teach-back through the qualified interpreter after each major teaching point. The interpreter documents completion of the encounter. The nurse stops the consent process until accurate language assistance and accessible information are available. The team confirms that family involvement will follow the client's preference rather than replace the client's decisions.
護理紀錄
1440：護理師觀察一位英語能力有限的個案進行入院訪談。圖表顯示個案偏好的口說和書寫語言已記錄在入院紀錄中。1445時，工作人員表示個案的未成年子女將擔任用藥史的口譯。護理師取得合格的視訊口譯員，且螢幕位置讓個案可以看到雙方參與者。同意書討論開始，但一位來訪的鄰居被要求解釋程序與風險。訪談期間，臨床人員只對成年家屬說話，而不是直接對個案說話。口譯員在每個簡短段落後暫停，且個案有時間直接回答。出院資料已準備好，但重要的用藥警告僅以英文提供。個案要求配偶在場，且所要求的支持者在個案同意下留下。1500時，護理師在每個主要衛教重點後，透過合格的口譯員使用回覆示教。口譯員記錄此次會面的完成。護理師暫停同意書流程，直到有準確的語言協助和可近性資訊可用。團隊確認家屬的參與將遵循個案的偏好，而非取代個案的決定。