Long-Term Care Survey Alert

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. 
_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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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