Standards › Standard 25 › Policies
Policy · HMG-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 25.3
At a glance
- A trained interpreter or cultural mediator is used for each consultation where the language differs.
- A child is never used to interpret.
- A family member interprets only when no other option exists and the situation is not high-risk.
- Each use is recorded on HMG-REG-001.
- Stop and get help straight away if: a child interprets a diagnosis for their parent.
1. Purpose
To make sure language-discordant consultations are interpreted by trained people, never by children (25.3).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Children should never be asked to interpret for their parents, and a patient who cannot follow the conversation cannot consent. A trained interpreter or cultural mediator is needed for language barriers.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for migrant health | Owns the interpreter rule and the register | Clinician |
| Reception and clinical staff | Book the interpreter and record it | Staff |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Book.
- Book a trained interpreter or cultural mediator for each language-discordant consultation.
Key point: Booked.
Step 2. Use only the permitted person.
- Do not use a child. Use a family member only when no other option exists and the situation is not high-risk.
Key point: Permitted person used.
Step 3. Record.
- Record the interpreter used on HMG-REG-001.
Key point: Recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Language-discordant consultations with a trained interpreter or mediator | 100% | Monthly | Clinical lead for migrant health | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HMG-REG-001 | Interpreter and mediator use register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO and IOM Global Competency Standards for Refugee and Migrant Health and the WHO mhGAP Intervention Guide (2019). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)