Intermountain Rt Healtheare Phy PGE Medical Spanish Speaking Assi ent Vi3/to Employee Name: Date ‘Supervisor Nancy Park Megan Potter Anderson “BAD SCREEN TERMINOLOGY. Please fansite the following: Pease very the patients Name, SSN and Address? ? ASS Qt Yo ‘Who is theypatients Employer? ¢v Who is the Gu 4 ete \00 % ‘Which Insurance camer do you have? What's your Ethnicity? ag this due to any actient? dnen wes the dave of me accicient? joule you tke to be lived in the facilty crectony? How would you fke to take care of the patient respohsibiliy today? Tolai score out of 100%: OTHER TERMINOLOGY- Please ransiete the following: S- Symptons Tresiren V7 Ceara 7 Partary Care Oofiar Referring Doctof yf Colonoscopy (77 MAL? CT Scat Kays VT Surgery J T Voucher 77 Shae v Maried sJ Bworced FT Widowed 7 Total score out of 100%: “SPANISH CONVERSATION: / |. Ask the patient if trey need girections or Go they know where they are going J 2. Askthe patient if thay have any other questions before completing the reuistration 7 JS 3, incicate co-the patient you found another sence here for them end if you can register them for thar too? Total score out of 100%: “FINAL TOUCH POINTS AND REMINDERS- 1. Your supervisor will recetve this report arid wil then touch base with you 2. Please remember to refer to the patient in the “Usted? formal format always Spanish Assessment completed by: waressed by: