Health Literacy Universal Precautions Toolkit, 2nd Edition

Communication Observation Form

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Please observe the interaction between a patient and a specific clinician or staff member. Answer the following questions either yes or no to provide feedback about the quality of the communication you observe. Feel free to write notes that can help the clinician or staff member to improve his or her communication in the future.

1. Did this clinician or staff member explain things in a way that was easy to understand? Yes No
2. Did this clinician or staff member use medical jargon? Yes No
3. Was this clinician or staff member warm and friendly? Yes No
4. Did this clinician or staff member interrupt when the patient was talking? Yes No
5. Did this clinician or staff member encourage the patient to ask questions? Yes No
6. Did this clinician or staff member answer all the patient’s questions? Yes No
7. Did this clinician or staff member see the patient for a specific illness or for any health condition? Yes No
If No, Form Is Complete
   a. Did this clinician or staff members give the patient instructions about what to do to take care of this illness or health condition? Yes No
If No, Form Is Complete
   b. Were these instructions easy to understand? Yes No
  c. Did this clinician or staff member ask the patient to describe how they were going to follow these instructions? Yes No

Please note any other comments about the encounter below:

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Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Communication Observation Form. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool4c.html