CULTURAL CONSIDERATIONS.

 

 

Cultural Considerations

 

United States is a country of many colors, many heritages, and many histories. Some refer to the United States as a "melting pot" because people from so many different cultures live here. At one end of the continuum are people who have come to the United States from other countries and have not changed their behaviors or beliefs. They live in small communities with people who have a similar cultural heritage. At the other end of the continuum are people who have come to the United States from other countries and changed from the "old country" beliefs and behaviors to those that better suit them. Between the two ends of this continuum are people with varying degrees of behaviors and beliefs that represent a blending of foreign and American influences. Culture is dynamic and constantly changing as a result of human interaction. As individuals interact with people and their physical and social environments, they create ways of naming, understanding, and managing their worlds. As each person interacts with new individuals and new environments, their culture may change. People within a culture share values, beliefs, and expected behaviors that define what is right, normal, and appropriate and what is wrong, abnormal, and inappropriate (McNaughton, 2002).

With cultural and ethnic diversity come many challenges. As a health care professional, you are challenged with the responsibility to work with and care for individuals who may not have the same skin color, language, health practices, beliefs, and values as your own. When this occurs, the goal is not to force the client and his or her family to comply with your beliefs, values, and health practices but instead to meet the client where he or she is and to work with his or her belief and value system. The challenge occurs not when the client is of the same heritage and speaks the same language as the nurse, but when the cultures and languages are different. Consider the following scenario:

You are caring for a 72-year-old Hispanic woman, Rosa Martinez, who speaks Spanish as her primary language. Conversing in broken English, she tells you that she has injured her lower back and now has continuing aches and stiffness. She does not want to be at the clinic but is here because her daughter forced her to come. She says that she hasn't seen a physician in years because Maria, her cuerandera, takes good care of her. When you inquire whether she has seen Maria for her back, she replies yes and then goes on to tell you that Maria had given her an herbal formula to take internally and had made herbal poultices to use at home. The client tells you that she believes that these remedies are working and she is not sure why her daughter made her come to the clinic.

 

The nurse caring for Mrs. Martinez is potentially challenged by three issues: (1) the language barrier; (2) an alternative health care provider, Maria the cuerandera, in whom Mrs. Martinez has much confidence; and (3) the use of alternative folk remedies—the herbal formulas and poultices. How the nurse interacts with this client and her family will depend partly on the nurse's own heritage and culture and partly on her knowledge of and attitude toward other cultures and other cultural health beliefs and practices.

As health care professionals we are not responsible for knowing about the health beliefs, practices, and values of all of the cultural and racial groups other than our own, because the diversity among us is so great. We are responsible for asking the client about his or her health beliefs, practices, and values because knowing this information is essential for individualizing care. A person may be from one of the major racial and cultural groups, such as Native American, African American, Asian, white American, or Hispanic, or one of the often unrecognized cultural groups, such as the homeless, migrant workers, gay men, or lesbians. To improve cultural awareness and sensitivity, however, you can ask questions to gather information about the unique beliefs and value systems of individuals of other cultures and backgrounds.


Culture, ethnicity, and race are terms used to learn about cultural awareness. Culture is defined as all of the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, life ways, and characteristics of a population that influence perception, behavior, and evaluation of the world. Ethnicity refers to a social group within a cultural and social system that shares a common social and cultural heritage, including language, history, lifestyle, and religion (Fig. 3-1). Cultural background is a fundamental component of one's ethnic background. Ethnicity is indicative of some of the following characteristics that a group may share in some combination: common geographic origin; race; language and dialect; religious beliefs; shared tradition, values, and symbols; literature, folklore, and music; food preferences; settlement and employment patterns; and an internal sense of distinctiveness (Spector, 2000). Race is genetic in origin and includes physical characteristics such as skin color, bone structure, eye color, and hair color. The Human Genome Project provides evidence that all human beings share a genetic code that is more than 99% identical. Although less than 1% difference exists in genetic code, the differences are evident when performing health assessments. People from a given racial group do not necessarily share a common culture (Purnell & Paulanka, 2003).


To emphasize the importance of culturally and linguistically appropriate services in health care, the U.S. Department of Health and Human Services (USDHHS) Office of Minority Health (OMH) issued national standards to ensure that all people entering the health care system receive equitable and effective treatment (Fig. 3-2). These 14 standards provide for culturally and linguistically appropriate services (CLAS) to help eliminate racial and ethnic health disparities and to improve the health of all people who live in the United States of America. Although the CLAS standards are primarily directed at health care organizations, individuals in the health care system are encouraged to use the standards to make their practices more culturally and linguistically accessible. The standards are organized around three themes: culturally competent care, language access services, and organizational supports for cultural competence. As a nurse, you will be affected by Standard 1, which states that "healthcare organizations should ensure that clients/consumers receive from all staff members effective understandable and respectful care that is provided in a manner compatible with the cultural health beliefs and practices and preferred language" (USDHHS, OMH, 2001). Improving cultural awareness, as well as meeting Standard 1 of CLAS, require several steps. First, develop sensitivity to the differences between your own culture and the client's; second, don't stereotype; and third, develop a template that may be used for cultural assessment of the client and the family.

 

Become Culturally Competent

Cultural competence is the ability to communicate between and among cultures and to demonstrate skill in interacting with and understanding people from cultures other than your own. A culturally competent nurse communicates in a way that allows clients to explain what an illness means; respects the concepts of time, space, and contact of the client; and respects physical and social activities of clients. This nurse respects systems of social organization and provides as much of a sense of environmental control as is possible (McNaught, 2002). Box 3-1 describes ways to achieve cultural competence.

 

During times of medical needs there sometimes comes a need to understand your patient's cultural needs. What may be acceptable for one cultural group may not be for another. By learning some simple cultural or ethnic considerations you will be able to provide a higher level of care to your patient. In no way is this article meant to be complete or to suggest that all people from cultural background fall into these exact categories as not everyone in a particular group follows the practices or shares in all the beliefs or characteristics of one culture.

Eye Contact:


Native American, Southeast Asian, and Arab: view eye contact during conversation as impolite or improper.

Appalachians: Direct eye contract from strangers can be perceived as hostility or aggression

Asian: Are reluctant to maintain eye contract with elders or superiors while they may expect their nurse to be looking them in the eye because they view the nurse as a superior they may look at the ground or hesitate before responding to questions. Eye contact can also be perceived as improper and impolite to look someone in the eye during conversation.

Muslim/Arab Women - may avoid eye contract with men due to being modest.

Personal Space and Touch:

Canadians, British, and Americans: Require several feet to maintain a comfortable level of personal space. These groups of people require the largest personal space over other cultures.

Middle East, Latin American and Japan: View larger personal spaces as a form of rejection or an insult. Their personal space needs are much less.

Europeans: Often show a sign of affection by patting a child on the head.

Asian: Feel touching a child on the head is a show of disrespect and also believes that this can cause illness. When dealing with an Asian family a safer approach to touching a child is to touch an upper extremity while talking to assessing a child.

Mediterranean regions and Hispanic groups: Believe in frequent touch.

Middle Eastern Cultures: Do not believe in the touching of a male other than a women's husband is unacceptable.

If you work in an area where you work with a high diversity of cultures it is essential that you do some background work into someone's culture so that you are able to promote quality care without offending your patient. By understanding ones cultural needs you are able to offer a more holistic approach to your nursing care. Remember as a nurse you are responsible to become familiar with the cultures of your area.

Cultural Values, Ethics, and Ethical Conflicts

Cultural values refer to enduring ideals or belief systems to which a person or a society is committed. The values of nursing in the States are, for example, embedded in the values of the U.S. American culture with its emphasis on self-reliance and individualism. Basic to the value placed on individualism are the beliefs that "individuals have the ability to pull themselves up by their bootstraps" and that an individual’s rights are more important than a society’s. 

However, many cultures do not share the primacy of the value of individualism. Consider the factual data presented by Davis that about 70% of all cultures are collectivistic (i.e., loyalties of a person to a group exceed the rights of the individual) rather than individualistic (i.e., the rights of the individual supercede those of the group). "With individualism, importance is placed on individual inputs, rights and rewards". In many cultures, health decisions are not made by an individual but by a group: family, community and/or society. Socialized medicine or government sponsored health care for all residents is reflective of the value placed on collectivism.

Therefore, reflecting on the values that predominate in the culture you practice, attain an education, visit, or read about is a requirement for ethical thoughtfulness. Ethics has many definitions but, typically, ethics is viewed as a systematic way of examining the moral life to discern right and wrong; it also requires a decision or action based on moral reasoning. Ethical conflicts occur when a person, group or society is uncertain about what to do when faced with competing moral choices Ethical conflicts and issues occur within or among cultures and are usually precipitated by cultural/subcultural values in opposition. 

Conflict and Globalization

Certainly members of any culture may hold varying degrees of commitment to the predominant values of the culture, but being in opposition to those values sets the stage for conflict. Even countries where people were once relatively isolated from other cultures or were homogenous (e.g., Asian cultures) are also becoming more culturally diverse. Why? Through increased communication, travel, and trade, differing perspectives have been imposed upon the cultural beliefs and ethical values of people because they are believed to be right or better (ethnocentrism at work). For example, North Americans and others with Western ethical perspectives who live in their own homelands may, unwittingly, export products abroad like textbooks, curriculums, and used equipment. These products, even though well intentioned, may present a cultural imposition. In addition, the altered attitudes of international students who return to their homeland after a westernized education in a capitalistic culture are a source of inculcating new but perhaps unsettling ethical perspectives on a country or profession. Globalization, with its outcome of increased cultural diversity, has not only given nurses pause for thought but also has contributed to ethical conflicts. 

Davis recognizes how ethical conflicts and issues can arise, especially when nurses acknowledge the profound influence that the values of nurses in the United States have had on other countries worldwide. The value on individualism, for U.S. nurses, for example, can be examined in relation to the ethical principles of autonomy and justice. The ethical principle of autonomy is related to self- determination, that is, the individual’s right to make decisions for him or herself. Consistent with this principle is respect for the autonomy of others. Therefore, the lack of respect for the decision-making of culturally diverse people in nursing practice is unethical.

The other principle, justice, which deals with what is due or owed to an individual, group, or society, has numerous definitions. For this discussion, we focus on two conflicting material principles of justice that cause ethical conflict: 1) "to each person according to what can be obtained in a free market, " 2) "to each person based on need." 

The first material principle of justice has autonomy as its underpinning. It is in keeping with a supply and demand situation where some persons will possess or benefit more than other persons. A problem with this principle is that it can lead to inequalities in society’s burdens and benefits.

The second material principle of justice has fairness as its underpinning. It is sensitive to individual differences and to factors over which the person has no control. A problem with this principle is how to honor it when resources are finite or scarce.

While we have only examined ethical conflicts that evolve from the U. S. cultural emphasis on individualism and the related ethical principles of autonomy and justice, there are many other examples of conflicts that can be and should be examined, but go beyond the scope and purpose of this column. However, we leave the reader with two questions to consider that are particularly cogent to a discussion on ethical conflicts: "…is it justified to strive for uniformity of nursing practice on the basis of ethics across all cultures?" and "…are there ethical notions of caring, ethical principles and virtues, that could be endorsed as true for all nurses everywhere?"). 

Nursing Strategies to Decrease Ethical Conflicts Related to Cultural Values and Diversity

Of the many nursing theories used in the United States today, the one most associated with culture and cultural values is Leininger’s Culture Care Diversity and Universality: A Theory of Nursing. In the mid-1950s she first observed that nursing practice lacked attention to cultural and humanistic factors. It was from these observations and from further writing and research on the topic that the preceding book was written Implicit to her theory is the importance of communication between patient/client and the provider(s) of care. As Donnelly succinctly states, "...ethical issues become more prominent when a lack of communication occurs" (p. 124). Lack of communication is more likely to occur when nurses care for international and culturally diverse persons. The resultant misunderstandings can lead to lack of respect for persons whose cultural values are different from one’s own and to potential and real harm to those persons, whether culturally, psychologically, physically, or spiritually.

How can the situation be improved? Here are some suggestions to improve communication and nursing care and, thus, decrease ethical conflicts:

Recognize that values and beliefs vary not only among different cultures but also within cultures. 

View values and beliefs from different cultures within historical, health care, cultural, spiritual, and religious contexts. 

Learn as much as you can about the language, customs, beliefs and values of cultural groups, especially those which you have the most contact. Related Links from Transcultural Nursing: Basic Concepts and Case StudiesAvailable: 

Be aware of your own cultural values and biases, a major step to decreasing ethnocentrism and cultural imposition. (A questionnaire that can help you with this goal can be found in ). 

Be alert to and try to understand the nonverbal communications of your own and various cultures such as personal space preferences, body language, and style of hair and clothing. 

Be aware of biocultural differences manifested in the physical exam, in types of illness, in response to drugs, and in health care practices.

Terms & Definitions

Ethnocentrism - A person’s belief in the inherent superiority of one’s own culture over that of other cultures.

Cultural Imposition - A situation where one culture forces their values and beliefs onto another culture or subculture.

Cultural Importation - A situation where one culture buys or brings in products and goods from foreign countries (cultures) to be used or sold in the importing culture.

Cultural Exportation - A situation where one culture sends products or goods to foreign countries (cultures) to be used or sold in the exporting culture.

Belief Systems - A totality of enduring facts, principles and values that a person or a  culture deems to be true or to be trusted.

Norms - Standards that are accepted, often implicitly, by a culture.

Assumptions

Goods or products imported/exported intact to another culture may not meet the needs of that culture or therefore, may need modification. 

Both ethnocentrism and cultural imposition show insensitivity to the culture(s) who receive them. 

Both belief systems and norms are needed for a stable culture.

 

 

Defining the "Ism's" of Cultural Diversity
Examining what is known as the “Ism’s “ of cultural diversity is the starting point to understanding our own belief and value patterns. Consider the following definitions and how as a society we must take care to counteract such biases, discriminations and social injustices.

Cultural Assessment
To complete a thorough cultural assessment on each patient that is admitted to the hospital is not only time consuming, but also nearly an impossible feat given the short amount of time a nurse is allotted to spend with each of her patients. Before you sit down to gather information from your patient, ask yourself the following questions.

Awareness
Am I aware of my biases and prejudices towards other cultural groups, as well as racism in healthcare?

Skill
Do I have the skill of conducting a cultural assessment?

Knowledge
Am I aware about the worldviews of different cultural and ethnic groups, as well as have knowledge in the field of bicultural ecology?

Encounters
Do I seek out face-to-face interactions with individuals who are different from myself?

Desire
Do I really "want to" become culturally competent?

Once you completed your own personal assessment, you are ready to proceed. The following questions are ones you should ask your patient to help you create a plan of care that will be most beneficial to them.

Cultural Communication
Even when nurses and patient’s speak the same language, mis-communication can occur because of differences in values and beliefs. Magnify this by the fact that the patient you are caring for has a cultural background that you are not familiar with, and the potential for mis-communication grows even greater. In addition to verbal communication, non-verbal cues that may represent different meanings can add to the communication dilemma. The following are considerations to keep in mind when conversing with a patient who is from a different culture then your own.

Communication Barriers

Communication with American Indian patient’s
Major language and dialects – most American Indians speak English. Some often use anecdotes or metaphors to discuss a situation. Verbal discourse may be carefully constructed to provide precise meaning through examples.

Literacy assessment – If vocabulary is limited an interpreter may be needed.

Nonverbal communication – Respect communicated by avoiding eye contact and keeping a respectful distance is recommended.

Greeting – Light touch or handshake. Do not refer to men as chiefs or women as squaws.

Tone of voice – Tone expresses urgency, when something is imperative be direct.

Communication with African American patient’s
Major language and dialects – Most African Americans speak English. Some use traditional dialects in the Carolinas, Alabama and Louisiana. Black English a very expressive dialect is sometimes spoken in the inner cities. People may switch from Black English to Standard English depending on the situation.

Literacy assessment – Refusal to sign documents or consent could indicate a literacy problem. Ask what level of education the patient has completed.

Nonverbal communication – African Americans are affectionate people, they hug and show affection by touching. Eye contact shows respect, and any overt silence on the part of the patient, may be a sign of distrust for the caregiver.

Greeting – African Americans prefer to be addressed as Mr., Mrs., or Miss., followed by their last name. A handshake is appropriate.

Tone of voice – When speaking to each other, conversation can get loud and animated. This may be the same if they are feeling anxious or nervous.

Communication with Arab American patient’s
Major language and dialects – Arabic. Please note that Egyptians also speak “Egyptian Arabic”. Different Arab countries and regions use different dialects that give different words different meanings. Although their alphabet is very similar, Iranians and Arabs do not understand each other’s language.

Literacy assessment – Arab professionals speak fluent English. Though some admit to speaking and understanding English moderately, they may have difficulty understanding health professional’s explanations and directions. Arabs tend to repeat things if they feel they are not being understood so saying you understand and repeat what is being told to you will clarify this.

Nonverbal communication – Arab Americans are expressive, warm and other-oriented. They may at times present with a flat affect to protect their true feelings. They are more comfortable with closeness from the same sex. They are very polite and may not disagree openly with what is being asked of them.

Greeting – Greet using title and first name. Approach by shaking hands and acknowledging the country of origin and something personal about the patient or family.

Tone of voice – Loud voice means message is important. Anger usually is expressed in a high intense voice by patient or family members.

Communication with Chinese American patient’s
Major languages and dialects – Cantonese and Mandarin are the most common languages spoken.

Literacy assessment – The ability to speak and read varies from individual to individual. Elderly Chinese (especially women) may not be able to read and write. Avoid yes and no questions and attempt to ascertain whether true understanding is occurring or not.

Nonverbal communication – Eye contact and touching is noted between family members, but avoiding eye contact with elderly patients is seen as a sign of respect. Keeping a respectful distance is also recommended.

Greeting – Chinese people are often shy in an unfamiliar environment. Address elders with Mr./Mrs. and their last name. Use of the first name when initial contact is made can be viewed as disrespectful.

Tone of voice – The Chinese language is very expressive and sometimes loud. Often this loudness is interpreted as abrupt.

Communication with Filipino American patient’s
Major language and dialects – Filipino (Tagalog) is the national language. There are however more then 85 languages and dialects spoken. Most Filipinos do speak English as a second language.

Literacy assessments – Most Filipinos speak and understand English. Using simple medical terms will assist them in understanding.

Nonverbal communication – Typically shy and affectionate. They are sometimes awkward in unfamiliar surroundings and want family members to share their space for comfort and support.

Greeting – A smile or facial expression is frequently used as a greeting, a handshake is not commonly practiced. Family members show elders respect by kissing their hand forehead or cheek.

Tone of voice – Filipino language as a practical language is not very rich. Changing the tone of their voice is done often to evoke emotion and romanticize the language.

Communication with Korean American patient’s
Major language and dialects – older generations speak Korean, though younger generations most often speak English.

Literacy assessment – Elders may have learned to understand English from younger generation, but still may not be able to read or write English. Understanding health care terminology may require an interpreter.

Nonverbal communication – When in the comfort of friends and family, touching and hugging is acceptable. With strangers, touching is considered disrespectful except in the case of a physical examination. Personal space is frequently shared with each other but not with strangers. Silence is viewed as a tranquil, peaceful time that can be used for prayer and meditation. When conversing with each other, Korean’s are very excitable animated in communication.

Greeting – The use of Mr./Mrs./Miss and the last name unless the patient requests otherwise. Respect towards elders and authority is constantly demonstrated.

Tone of voice – Tone has a wide variety of pitches with emphasized loudness depending on what the speaker feels is important. Commands are given differently dependant on whether they are intended for an elder or a child.

Communication with Mexican American patient’s
Major language and dialects – Some speak Spanish exclusively but the majority are bilingual and speak English as well. There are many indigenous languages in Mexico that give different meanings to different words depending on the region that one lives.

Literacy assessment – There is a great diversity in educational levels. First generation females who do not work outside of the home tend to be less likely to speak English. Younger Mexicans are more likely to not only speak English, but also read and write English. It is important to assess reading/writing skills and provide simple verbal and visual aids as appropriate.

Nonverbal communication – Respect strongly influences the use of nonverbal communication. Direct eye contact is frequently avoided when one is considered an authority. Family members may stand when someone enters the room as a form of respect. Silence sometimes shows a lack of agreement. Touch by strangers can be perceived as disrespectful and can be very stressful.

Greeting – Using formal names is considered respectful. Formal greetings should be used with elders and women. As time passes and increased comfort with caregiver is perceived, a less formal greeting is required.

Tone of voice – A respectful and polite tone is usually used. Mexican American’s are very warm and expressive. They can be noted to be reserved and quiet in an unfamiliar setting.

Communication with Vietnamese American patient’s
Language and dialects – The three major languages spoken by the Vietnamese are Vietnamese, French and Chinese. Many have adopted English as their second language, but the ability to read/write English must be assessed.

Literacy assessment – If patient is unable to read or write English there is usually a family member present at all times who can assist them with this.

Nonverbal communication – A gentle touch may be appropriate when conversing with younger generations, but with elders and more traditional Vietnamese people touching is limited. Avoiding eye contact with those of higher standing shows respect. Slightly bowing head is a way to show respect.

Greeting – In a formal setting, the family name (which is the last name mentioned first) is the name of choice. In a more casual setting, using the given or first name is acceptable. Vietnamese greet with smile and bow rather than a handshake. Caregivers should not shake a woman’s hand unless she extends it first.

Tone of voice – typically soft spoken. Raising the tone of voice and pointing a finger are a sign of great disrespect. Indirectness and restraint rather that confrontation are the preferred method of communication.

Characteristics of Immigrant and Refugee Families
The United States is known as a “melting pot” because except for the American Indians, we are all immigrants. Some came to the United States by choice, some were deposited here, some were sold into slavery and others were just looking for a safe haven and did not care what country that haven was to be found. In considering a care plan for your patient, understanding how and why they got here, will assist in care that brings positive outcomes. The following are some characteristics of immigrant and refugee families that should be taken into consideration:

History of Immigration
American Indians – American Indian societies had rights to all land now in the US and slowly lost communal rights to all but areas specifically designated as federal or state reservations. Following World War II resettlement in urban areas occurred and this is where most Indians now live.
 
African Americans – Jamestown Virginia is where the first 20 black slaves landed in 1619. In the 18th and 19th century the number would reach 8 million. Important historical influences included emancipation, migration, to big cities and the civil rights movement. Immigrants from the Caribbean Islands and some parts of Africa share some history but are perceived differently.
 
Arab Americans – In the early 1800’s Middle Easterners began to arrive. From 1875-1940 was when the first serious immigrants came from what was known as Greater Syria. From 1940-1970 a second wave of immigrants arrived largely because of political events, wars and loss of homes. The creation of the State of Israel in 1948 is thought to have been a big driving force in Arab immigration to the U.S. From 1970-1990 the third wave of immigrants arrived in the U.S. largely because of war and economic deterioration.
 
Chinese Americans – From 1840-1882 Chinese laborers came to the U.S. for jobs. Many worked on the railroads. From 1882-1964 various acts and quotas such as the Chinese Exclusion Act and the National Origins Quota Act temporarily suspended and limited the number of Chinese immigrants that could migrate to the U.S. In 1965 these acts were abolished, and by 1970 the U.S. population of Chinese had grown 84%.
 
Filipino Americans – The first wave of Filipino’s came to the U.S. from the early 1700’s to 1934. These were Manila men who separated from the Spanish galleons in Mexico and emigrated to New Orleans and later to Hawaii to work. The second wave of immigrants came between 1946-1965 when citizenship to Filipino’s who joined the WWII efforts drew recruits, war brides, students and professionals. In 1965 the third wave which was when the Amended Immigration Naturalization Act of 1934 relaxed quotas and allowed a large number of professionals and their families to migrate.
 
Korean Americans – From 1903-1920 approximately 8,000 Koreans came to the U.S. to settle in Hawaii. From 1950-1965 approximately 17,000 Koreans entered the U.S. the majority being spouses of American citizens due to the War Brides Act of 1947. In 1965 the Immigration Act opened the gates for a major wave of Asian immigration.
 
Mexican Americans – The Mexican/American War of 1846 resulted in the loss of nearly half of Mexico’s territory. Mexican inhabitants of ceded lands were offered U.S. Citizenship with the promise of some property rights. There were 80,000 people who lived in the territory and became American Citizens. The early 1900’s Mexicans were recruited to work as laborers for the railroads when Chinese labor was banned; there was also a need for laborers during WWI. The Great Depression of the 1930’s and 1940’s caused a large deportation of Mexicans back to Mexico (458,000). From 1964-1986 the establishment of boarders and lack of work in Mexico caused an increase in undocumented immigration to the U.S. From 1986-present the Reform and Control Act increased family reunification. More skilled people settled in the urban centers and competed for jobs in the service industry.
 
Vietnamese Americans – From 1975-1977 a variety of well educated professional migrated to the U.S. From 1980-1986 this second wave of immigrants were known as the “boat people” or refugees. This group escaped on their own to seek freedom from persecution. Many spent time in refugee camps.

Expressions of pain
Pain, which is a universally recognized phenomenon, is a very important area for a nurse to consider when taking care of multi-cultural patients. Being able to understand not only how pain is perceived, but also how it is expressed will have a significant impact on the nursing interventions. In terms of pain measurement, it is not only necessary to assess the pain threshold and individual tolerance, but also the cultural norms and influence that surround the issue of pain. The following list discusses specific cultures and how they perceive and express feelings of pain or discomfort.

American Indians – Pain is generally under treated with American Indians because in this culture is usually not specific to what is hurting them. Often statements such as “I don’t feel well”, or “something isn’t right” are expressions that will be used to describe pain. American Indian patients may complain to a trusted family members about specific pain, so in when assessing for pain, the nurse may find it beneficial to interview family members.

African Americans – Expressions of pain are generally open and public, but can as with all individuals tend to vary in degree. Using a 1-10 pain scale with this group is most effective. Of important note, some African Americans are hesitant to take pain medication for fear of becoming addicted. As the nurse it is important to educate the patient to the addiction risks of pain medication when treating severe pain.

Arab Americans – This cultural group is very vocal and expressive about pain, particularly if other family members are present. Pain is feared and sometimes causes panic when it occurs. The goal for this group is to do whatever is necessary to avoid pain altogether. If this cultural group understands the cause and prognosis for the pain, they are much more likely to deal with it appropriately. As the nurse, when dealing with African American patients who are suffering in pain, begin patient education regarding pain as soon as possible.

Chinese Americans – This cultural group most likely will not complain of pain. It is important to be aware of non-verbal cues when assessing for pain. Offering pain medication rather than waiting for the patient to request it will assist with proper pain management. Acupuncture and acupressure are alternatives that this group may use to control pain.

Filipino Americans – Stoic is the term that best describes this group when it comes to pain. As with the Chinese Americans offering pain medication rather than waiting for the patient to request it will assist with proper pain management.
Some Filipino Americans have a high pain tolerance and this might also be a reason why they do not request pain medication. “Moaning” is the most notable sign that pain is being felt. This population prefers PO or IV routes of medication and are sometimes fearful of medication that is given IM.

Korean Americans – “Ah-poom nida” means much pain and “chegesso” or “chegetta” are terms that mean “I think I might die”. For the very stoic of this population, a pain scale may be not be tangible. Instead ask “how bad is the pain” in order to get a better idea for treatment. For those who are more dramatic in expressing pain, moaning and flailing around is not unusual. Fear of addiction and/or complications makes pain management for this group sometimes difficult.

Mexican Americans – Verbalization of pain is not common but non-verbal cues are often used. For some (especially men) showing outward signs of pain is viewed as being weak. In women expression of pain is more acceptable. Using a pain scale is effective with this patient population.

Vietnamese Americans – “Dau” means pain in Vietnamese. This patient population tends to be stoic about pain. Offering pain medication rather then waiting for the patient to request it will assist with proper pain management. Some may understand a numerical pain scale if not, use facial expression of pain and then ask “how severe is it”. Fear of addiction and/or complication with this patient population as well can make pain management difficult.




Every individual on this earth is unique. Regardless of a person's skin color, physical features, cultural heritage, or social group, realize that individual's uniqueness. Cultural heritage plays an important part in helping to identify the individual's "roots" and perhaps helps to explain attitudes, beliefs, and health practices, but each major cultural group is made up of unique individuals and families who may have values and attitudes that differ from the cultural norm. Don't assume that because individuals or families are Asian or Pacific Islander they all share culturally similar beliefs. For example, within the Asian or Pacific Islander people are Chinese, Filipino, Japanese, Asian Indian, Korean, Vietnamese, Cambodian, Thai, Bangladeshi, Burmese, Indonesian, Malayan, Laotian, Kampuchean, Pakistani, Sri Lankan, Hawaiian, Samoan, Tongon, Tahitian, Palauan, Fijian, and Northern Mariana Islanders, and each of these groups has a unique heritage and set of beliefs.

Personal beliefs and knowledge about other cultures in the United States have been influenced by stereotyped images and misinformation presented through the media, educational and political institutions, and family beliefs.

Some common misbeliefs and stereotyped images include the following:

• All African Americans have large families.

• All welfare recipients are minorities.

• All Asians excel in math and science.

• All Native Americans live on reservations.

• All Hispanics speak Spanish.

If you learn nothing else from this text, learn that we are all unique individuals deserving of a unique and personalized assessment of our beliefs, our values, and our culture.

To illustrate the fallacy of stereotyping, consider the analogy of assuming that all clients who have type 1 diabetes mellitus have renal failure, visual impairment, and an amputated extremity. You would assess those clients to determine their unique characteristics. Likewise, you do not assume that all people who are Catholics are opposed to divorce just because it is a belief of the religion (Dreher and MacNaughton, 2002). You would ask each client questions selected from a template for assessment that you thought were applicable.

 

Develop A Template For Assessment

When assessing the client and family, it is important to include a direct assessment of the client's health beliefs and practices that may reflect his or her cultural heritage. Knowing the risks of stereotyping, perform a focused interview that will provide information about the client's personal beliefs, values, and attitudes.

Introductory Questions

• Where were you born?

• With what particular cultural group (or groups) do you identify?

• What Is the Client's Primary Language and Method of Communication?

• What is the language that is usually spoken in your home?

• How well do you speak, read, and write English?

• In what language do you think?

• Do you have to translate in your mind when communicating in English?

• Will you need the services of a translator during the time you are in this health care facility?

•Are there special rituals of communication in your family? (For example, is there someone special to whom questions should be directed?) Tell me about these.

• Are there unique customs in your culture that influence nonverbal or verbal communication? Tell me about them.

• What are some signs of indicating respect for others?

• What are appropriate ways to enter and leave situations?

What Are the Client's Personal Beliefs About Health and Illness?

• How do you define health and illness?

• Do you believe that you have control over your health? If not, what or who do you believe controls your health?

• What are some of the practices or rituals that you believe will improve your health?

• Do you or have you used any of the alternative healing methods, such as acupuncture, acupressure, ayurveda, healing touch, or herbal products? If so, how effective was the treatment?

• Whom do you consult when you are ill?

• What are specific practices or rituals that you believe should be used to treat your health problem?

• What are your attitudes toward mental illness? Pain? Handicapping conditions? Chronic disease? Death? Dying?

• Who makes the health decisions in your family?

• What health topics do you feel uncomfortable talking about?

• What examination procedures do you feel modest about?

• What can the members of the health care team do to help you stay healthy (or become healthy again)?

What Religious Influences and Special Rituals Affect the Client?

• Is there a particular religion that you practice?

• Whom do you look to for guidance and support?

• Are there any special religious practices or beliefs that are likely to feel supportive when you are ill?

• What events, rituals, and ceremonies are considered important within your life cycle, such as birth, baptism, puberty, marriage, and death?

What Are the Roles of Individual People in the Family?

• Who makes the decisions in your family?

• What is the composition of your family? How many generations or family members live in your household?

• When the marriage custom is practiced, what is the attitude about separation and divorce?

• What is the role of and attitude toward children in the family?

• When the children are punished, how is it done, and who does it?

• What are the major important events in your family? How are they celebrated? Do you or the members of your family have special beliefs and practices surrounding conception, pregnancy, childbirth, lactation, and child rearing?

Does the Client Have Special Dietary Practices?

• What is the main type of diet eaten in your home?

• Are there special types of foods that are forbidden by your culture or foods that are a cultural requirement in observance of a rite or ceremony?

• Who in your family is responsible for food preparation?

• How is the food in your culture prepared?

• Are there specific beliefs or preferences concerning food, such as those believed to cause or cure illness?

 

Remember

The most important behaviors in cultural assessment are to be sensitive; to ask questions; to gather information specific to the individual client; to not stereotype; and to not assume that, just because you took care of a similar client last week, you know exactly how this client feels and what he or she believes.

Regardless of the client's race or cultural heritage, each individual is unique. Before you become involved in the detailed task of a physical assessment, first take the time to get to know the client and his or her family.

 

 

Health History

 

The two primary components of health assessment are the health history and the physical examination. Collection of assessment data is the first step in the nursing process and an expectation of nurses in clinical nursing practice (American Nurses Association, 2004). Together, the nurse and client use this database to create a plan to promote health, prevent disease, resolve acute health problems, and minimize limitations related to chronic health problems. Accomplishing this purpose involves meeting both the clients' expectations for health and the nurse's expectations for the health of those clients.

The purpose of the health history is to obtain subjective data from the clients. Information to be gathered includes how clients define health, whether they believe they can attain and maintain health, whether they believe they are responsible for their health, what health behaviors they practice now, and what unhealthy behaviors they are willing to change. The clients' expectations for health are based on their life experiences, the experiences of their families and friends, and the culture in which they live. The nurse has a broader view of health and compares a client's current state of health to a standard needed to attain or maintain optimal health and then determines how far away the client is from the desired standard.

Purpose of the Health History

The purpose of the health history is to identify not only actual or potential health problems but also your patient’s strengths. It should also identify discharge needs. In fact, a successful discharge plan begins on admission with the health history. To create a successful plan of care, you must take a holistic view of your patient and all that affects her or him. Remember: The plan you develop will be successful only if your patient is able to follow through with it after discharge. The purpose of the health history is to:

■ Provide the subjective database.

■ Identify patient strengths.

■ Identify patient health problems, both actual and potential.

■ Identify supports.

■ Identify teaching needs.

■ Identify discharge needs.

■ Identify referral needs.

 

Types of Health Histories

A health history may be either complete or focused. A complete health history includes biographical data, reason for seeking care, current health status,past health status, family history, a detailed review of systems, and a psychosocial profile. A focused health history focuses on an acute problem, so all of your questions will relate to that problem.

Complete Health History. The complete health history begins with biographical data, including the patient’s name, age, gender, birth date, birthplace,marital status, race, religion, address,education, occupation, contact person, and health insurance/social security number. It should also include the source of the health history and his or her reliability, who referred the patient, and whether or not the patient has an advance directive. Once you have obtained this information, you should then identify the reason for seeking healthcare, followed by a description of current health status.

The  past health history includes childhood illnesses, surgeries, injuries, hospitalizations, adult medical problems, medications, allergies, immunizations, travel, and military service. The family history will identify familial or genetically linked disorders. The review of systems provides a comprehensive assessment to determine your patient’s physiological status. Past or current problems may be identified and warrant further investigation.

The psychosocial profile gives you a picture of your patient’s health promotion and preventive patterns. It includes a description of health practices and health

beliefs, a typical day,nutritional patterns, activity/exercise patterns, recreational patterns, sleep/rest patterns, personal habits,occupational and environmental risk factors, socioeconomic status,developmental level, roles and relationships, self-concept, religious and cultural influences, supports, sexuality patterns, and finally, the emotional health status of your patient. Once you have completed the health history, summarize any pertinent data.

A complete health history provides a comprehensive, holistic picture of your patient. It screens for actual or potential problems and identifies your patient’s strengths and health promotion patterns. A complete health history may be obtained in a primary setting as a screening tool, in a secondary setting once your patient’s condition stabilizes, or in a tertiary setting to establish a baseline from which to develop your plan of care.


 

Focused Health History. A focused health history contains necessary biographical data, including the patient’s name, age, birth date, birthplace, gender, marital status, dependents, race, religion, address,education,occupation,contact person, and health insurance/social security number. It also includes the source of the health history and her or his reliability,who referred the patient,and whether or not the patient has an advance directive. You should then identify the reason for seeking care, followed by a complete symptom analysis.

In your past health history, address any areas that relate to the reason for seeking care, including diseases of high incidence in the United States, such as heart disease, hypertension, cancer, diabetes, and alcoholism. In your review of systems, ask questions about every system and how it relates to the presenting health problem. The questions in the psychosocial profile identify the impact of the presenting health problem on your patient’s life.

A focused health history may be indicated when your patient’s condition is unstable or when time constraints are an issue. Focused health histories may also be used for episodic follow-up visits for your patient. In this case,you have already obtained a detailed health history at an earlier point and have established the subjective database. During the follow-up visits, you need to obtain further subjective data to monitor and evaluate your patient’s progress. Once you have completed the focused health history, remember to document any pertinent findings.

Focused versus Comprehensive History. Deciding which type of health history to do depends on two factors: your patient’s condition and the amount of time you have.

Patient’s Condition. First, determine the condition of your patient. This condition may prohibit a detailed health history upon admission. For example, if you are working in the emergency department and John Harrison, a 49-year-old man, presents with acute chest pain, a comprehensive health history is not indicated. Instead,you should obtain a focused history while you perform a physical assessment, draw laboratory studies, obtain an electrocardiogram, and connect your patient to a cardiac monitor.When a patient is in acute distress, trying to obtain a complete health history not only is detrimental but also provides little valuable or accurate information. So ask key questions that focus on the acute problem; once your patient’s condition stabilizes, obtain a more detailed health history.

Amount of Time. Allot at least 30 minutes to an hour to obtain a complete health history. Be sure to let your patient know why you are asking these questions and that it will take time. If you do not have enough time to complete the history,do not rush. Instead, perform a focused history first, and then complete the history at later sessions.


Medical History versus Nursing History

The areas addressed and the questions asked during a medical health history are very similar to those in a nursing health history. However, some important differences exist. These differences are defined by the focus and scope of medical versus nursing practice. Although the history questions are similar, the underlying rationale differs. Remember: Physicians diagnose and treat illness. Nurses diagnose and treat the patient’s response to a health problem.

For example,Mary Johnson, an 81-year-old woman, is admitted to the hospital with a fractured right hip. The focus of the medical history would be to identify what caused the fracture in order to determine the extent of injury. The history would also try to identify any preexisting medical problems that might make her a poor surgical risk. The physician will use the data that he or she obtains to develop a treatment plan for the fracture.

Although the nursing health history also focuses on the cause of the injury, the purpose is to determine Mary Johnson’s response to the injury, or what effect it has on her. You will look at much more than the fractured hip. You will consider how the injury affects every aspect of her health and life. Your history will provide clues about the impact of the injury on her ability to perform her everyday activities and help you identify strengths she has that can be incorporated into her plan of care. You will also identify supports and begin your discharge plan. Then you will use the data to develop a care plan with Mary Johnson that includes not only her perioperative phase but also her discharge rehabilitative planning.

 

Setting the Scene Setting the Scene

Before you begin your assessment, look at your surroundings. Do you have a quiet environment that is free of interruptions? A private room is preferred,but if one is not available, provide privacy by using curtains or screens. Prevent interruptions and distractions so that both you and your patient can stay focused on the history.Make sure that the patient is comfortable and that the room is warm and well lit. If the patient uses assistant devices, such as glasses or a hearing aid, be sure that she or he uses them during the assessment to avoid any misperceptions.

Before you begin asking questions, tell your patient what you will be doing and why. Inform him or her if you will be taking notes, and reassure the patient that what he or she says will be confidential.However, avoid excessive note taking—it sends the message to your patient that the health history form is more important than he or she is. Also, if you are too preoccupied with writing and continually break eye contact, you may miss valuable nonverbal messages. Excessive note taking may also inhibit your patient’s responses, especially when discussing personal and sensitive issues such as sexuality or drug or alcohol use.

Be sure to work at the same level as your patient. Sit across or next to her or him.Avoid anything that may break the flow of the interview. If the interview is being recorded or videotaped, be sure to get your patient’s permission before starting. Position the equipment as unobtrusively as possible so that it does not distract you or your patient.

Your approach to your patient depends on his or her cultural background, age, and developmental level. Ask yourself,“Are there any cultural considerations that might influence our interaction?”“What approach is best, considering my patient’s age?”


 

Components of the Health History

A complete health history addresses health and illness patterns, health promotion and protective patterns, and roles and relationships.The parts of the health history that focus on health and illness patterns include the biographical data, reason for seeking healthcare,current health status, past health history, family history, and review of systems.You identify not only current health problems but also past health problems and any familial factors that place your patient at risk for health problems. Your patient’s health promotion activities, protective patterns, and role and relationship patterns are assessed through the psychosocial component of the health history. Here, you assess for risk factors that pose a threat to your patient’s health in every aspect of her or his life. Also, you need to consider your patient’s cultural and developmental status as it affects her or his health status.

Biographical Data. The biographical data provide you with direct information related to a current health problem, alert you to risk factors for health problems, and point out the need for referrals.Your patient’s ability to provide biographical data accurately reflects his or her mental status.

Biographical data include the patient’s name, address, phone number, contact person, age/birth date, place of birth, gender, race, religion,marital status, educational level, occupation, and social security number/health insurance. They also include the person who provided the history and her or his reliability as well as the person who referred the patient. Information on advance directives may also be obtained for hospital admissions. Also note any special considerations, such as the use of an interpreter.



 

Reason for Seeking Healthcare. Ask your patient why he or she is seeking healthcare; then document his or her direct quote. The patient’s reason for seeking care is usually related to the level of preventive healthcare —primary, secondary,or tertiary.

If the setting is a primary level of healthcare, there is usually no acute problem. The reason generally relates to health maintenance or promotion. For example, the patient states,“I am here for my annual physical examination.”

If there is an acute problem, ask the patient to state what the problem is and how long it has been going on. For example,“I have had chest pain for the last hour.” If your patient identifies more than one problem, she or he may be confusing associated symptoms with the primary problem. Help her or him clarify and prioritize the problems by asking questions such as, “Which problems are giving you the most difficulty?”. Usually, patients identify problems that affect their ability to do what they usually do. In an acute-care setting, the reason for seeking care is called the chief complaint. The chief complaint gives you the patient’s perspective on the problem, a view of the problem through his or her eyes.

At the tertiary level, the problem may be well defined, a chronic problem, or an acute problem that is resolving. In this case, the problem does not have the acuity or life-threatening urgency of an acute problem.

Current Health Status. Once you have identified the patient’s reason for seeking healthcare, assess her or his current health status. At a primary level of healthcare (no acute problem), the current health status should include the following:

■ Usual state of health.

■ Any major health problems.

■ Usual patterns of healthcare.

■ Any health concerns.

For example: Patient is Maryanne Weller, age 42, married,mother of three, full-time teacher.Usual state of health good.Has yearly physical with pelvic examination and dental examination. Last eye examination 1 year ago. Expresses concern regarding family history of hypertension and ovarian cancer.

Patients in secondary or tertiary healthcare settings have an existing problem. So you will need to perform a symptom analysis to assess your patient’s presenting symptoms thoroughly. Although many questions come to mind, your patient’s condition and time constraints may preclude you from going into too much detail. If so, you’ll need to zero in on several key areas to evaluate your patient’s symptoms. As you perform the symptom analysis, try to determine how disabling this problem is for your patient. Also ask if he or she has any medical problems related to the current problems and if he or she is taking any medications for this current problem.

The helpful mnemonic PQRST provides key questions that will give you a good overview of any symptom. Although you can ask additional questions, the following ones provide a thorough analysis of any presenting symptom:

■ Precipitating/Palliative Factors

Ask:What were you doing when the problem started? Does anything make it better,such as medications or certain positions? Does anything make it worse, such as movement or breathing?

■ Quality/Quantity

Ask: Can you describe the symptom? What does it feel like, look like,or sound like? How often are you experiencing it? To what degree does this problem affect your ability to perform your usual daily activities?

■ Region/Radiation/Related Symptoms

Ask: Can you point to where the problem is? Does it occur or spread anywhere else? (Take care not to lead your patient.) Do you have any other symptoms? (Depending on the chief complaint, ask about related symptoms. For example, if the patient has chest pain, ask if she or he has breathing problems or nausea.)

■ Severity

Ask: Is the symptom mild, moderate, or severe? Grade it on a scale of 0 to 10,with 0 being no symptom and 10 being the most severe. (Grading on a scale helps objectify the symptom.)


■ Timing

Ask:When did the symptom start? How often does it occur? How long does it last?

 

Past Health History. The past health history assesses childhood illnesses, hospitalizations, surgeries, serious injuries, adult medical problems (including serious or chronic illnesses), immunizations, allergies, medications, recent travel, and military service. The purpose is to identify any health factors from the past that may have a direct relationship to your patient’s current health status. For example, a history of rheumatic fever as a child may explain mitral valve disease as an adult.

The past health history also identifies any chronic preexisting health problems, such as diabetes or hypertension, which may directly affect the current health problem. For example, patients with diabetes often have poor wound healing.Also, even though the chronic disease may be well controlled, the current health problem may cause an exacerbation. For instance, a patient with well-controlled diabetes may need to adjust his or her medication when scheduled for surgery, because the stress of surgery can elevate blood glucose. In addition, the past health history can identify additional health risks caused by preexisting conditions.

The past health history may also explain your patient’s response to illness, healthcare, and healthcare workers. If she or he has a history of multiple medical problems requiring frequent hospitalizations, these experiences may affect her or his perception of healthcare either positively or negatively.

When obtaining the past health history, be sure to ask for dates, physicians’ names, names of hospitals, and reasons for hospitalizations or surgeries. This information is important if past records are needed.Also avoid using terms such as “usual,”“general,”or “routine.” For example, “usual” childhood illnesses vary depending on the age of your patient and available immunizations.




Family History. The  family history provides clues to genetically linked or familial diseases that may be risk factors for your patient. Ask about the health status and ages of your patient’s family members. Family members include the patient, spouse, children, parents, siblings, aunts and uncles, and grandparents. Ask about genetically linked or common diseases, such as heart disease, high blood pressure, stroke, diabetes, cancer, obesity, bleeding disorders, tuberculosis, renal disease, seizures, or mental disease. If the patient’s family members are deceased, record the age and cause of death.

The family history may be recorded in one of two ways.You can list family members along with their age and health status (see  Family History by Listing Family Members), or you can use a genogram (family tree). A genogram allows you to identify familial risk factors at a glance. When developing a genogram, use symbols to represent family members, and include a key to explain the symbols and abbreviations. Another tool that can be effective in taking a patient’s family history is an ecomap.




 

Review of Systems. The  review of systems (ROS) is a litany of questions specific to each body system. The questions are usually about the most frequently occurring symptoms related to a specific system. The ROS is used to obtain the current and past health status of each system and to identify health problems that your patient may have failed to mention previously. Remember, if your patient has an acute problem in one area, every other body system will be affected, so look for correlations as you proceed with the ROS.Then perform a symptom analysis for every positive finding and determine the effect of,and the patient’s response to, this symptom.The ROS also provides clues to health promotion activities for each particular system. Identify health promotion activities and provide instruction as needed.

 

Developmental Considerations. The last part of your health history is taking a psychosocial profile, but before you do this, consider the developmental stage of your patient.A person’s development crosses the life span. Developmental assessments are often performed on children because the developmental changes that occur at this age are very observable and measurable.Yet adults also go through developmental changes that you need to consider during the assessment. Illness and hospitalization can have a major impact on a child’s growth and development, by either halting its progression or regressing it to an earlier stage. For example,when Johnny, age 4, is admitted to the hospital for a hernia repair, he begins wetting the bed during the night, even though his mother assures you that he has been “potty trained” since age 3.

Several developmental theories exist and will provide a framework for your psychosocial profile.These theories focus on specific areas of development, such as physical, psychosocial, cognitive, and behavioral.

Identifying your patient’s developmental stage will help you determine the relationship between the patient’s health status and his or her growth and development. Because many of these theories do not cross the life span, do not limit yourself to one developmental model. Each theorist views development from a different perspective. So be open and choose the theory or theories that will best help you assess your patient’s development.








 

Psychosocial Profile. The psychosocial profile is the last section of the health history. This section focuses on health promotion, protective patterns, and roles and relationships. It includes questions about healthcare practices and beliefs, a description of a typical day, a nutritional assessment, activity and exercise patterns, recreational activities, sleep/rest patterns, personal habits, occupational risks, environmental risks, family roles and relationships (see Assessing the Family), and stress and coping mechanisms.

In a primary healthcare setting, the psychosocial assessment enables you to identify how your patient incorporates health practices into every aspects of her or his life.You can then teach and reinforce health promotion activities that your patient can incorporate into her or his everyday life. If she or he has an acute problem, the psychosocial assessment helps you determine the impact of this illness on every facet of the patient’s life and assists you in determining discharge planning needs. For your plan of care to be successful, the patient must be able to follow through with it after discharge.Help ensure success by identifying clues as you perform the assessment and then making appropriate referrals.








 

Documenting Your Findings

Once you have completed the health history, summarize pertinent findings and share them with your patient to confirm their accuracy. Then document your findings and begin to formulate a plan of care. Documentation of history findings varies from one healthcare facility to another. Many acute-care facilities use computerized programs that enable you to enter the history directly into the computer. Standardized nursing admission assessment forms that combine both history and physical assessments are also commonly used.

Regardless of the system, here are some helpful hints for documenting a health history:

■ Be accurate and objective.Avoid stating opinions that might bias the reader.

■ Do not write in complete sentences. Be brief and to the point.

■ Use standard medical abbreviations.

■ Don’t use the word “normal.” It leaves too much room for interpretation.

■ Record pertinent negatives.

■ Be sure to date and sign your documentation.