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HIND GENERAL HOSPITAL
Patient Satisfaction Questionnaire - In Patient
Dear Hind Hospital Client: We are pleased that you and your Doctor chose Hind General Hospital for your outpatient procedure. We hope that your stay with us was comfortable and pleasant. Our goal is to provide high quality medical care to our patients and their family members. That is why we invite your response to this questionnaire. With your help, we can evaluate how effectively we are meeting the challenge of providing you with quality health care. Your comments and responses will be thoroughly reviewed and kept strictly confidential unless you specify otherwise.
Thank you for your comments,
Hind General Hospital
INTRODUCTION
1. Was this your first stay at Hind General Hospital?
Yes
No
2. Was your admission unexpected?
Yes
No
3. Were you placed on a special diet or restrictions?
Yes
No
4a. Days in Hospital
4b. Dates you were in the hospital
-
-
to
-
-
5. Your Sex
Male
Female
7. Your Age
8. Your Name (OPTIONAL)
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
9. Compared to others your age you typically describe your health as
5
4
3
2
1
N/A
A. ADMISSION
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Speed of admission process
2. Courtesy of person admitting you
3. Rating on pre-admission process (if any)
Comments
(Describe good or bad experience)
B. YOUR ROOM
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Pleasantness of room décor
2. Room Cleanliness
3. Courtesy for the person that cared for your room
4. Room Temperature
5. Noise level in and around room
6. How things worked (TV,Call button, lights, phone etc)
Comments
(Describe good or bad experience)
C. MEALS
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. If you were placed on a special diet how well was it was explained.
2. Temperature of the food (Cold foods cold, hot foods hot)
3. Quality of food
4. Courtesy of the person who served your meals
Comments
(Describe good or bad experience)
D. NURSING CARE
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Friendliness of the nurses
2. Promtness in responding to call button
3. Nurses attitude toward your Request
4. Amount of attention paid to Your special or personal needs
5. How well the nurse(s) kept you informed
6. Skill of the nurses
Comments
(Describe good or bad experience)
E. TESTS AND TREATMENTS
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Waiting time for test or treatments
2. Concern shown for your comfort during test or treatments
3. Explanantions about what would happen during treatments/tests
4. Skill of person who took your blood (e.g. did it quickly, minimal pain)
5. Courtesy of the person who took your blood
6. Skill of the person who started your IV
7. Courtesy of person starting IV
Comments
(Describe good or bad experience)
F. VISITORS AND FAMILY
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Helpfullness of the people at the Information desk
2. Accommodations and comfort for visitors.
3. Staff attitude your visitors
4. Information given to your family about your condition
Comments
(Describe good or bad experience)
G.YOUR PHYSICIAN
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Time physician spent with you
2. Physician concern for your questions or comments
3. How well physician kept you informed
4. Friendliness of physician
5. Skill of physician
Comments
(Describe good or bad experience)
H. DISCHARGE
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Extent in which you felt to be discharged
2. Speed of discharge process
3. Instructions given about how to care for yourself at home
4. Help with arranging home Care services (if needed)
Comments
(Describe good or bad experience)
I. PERSONAL ISSUES
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Staff concern for your privacy
2. How well your pain was Controlled
3. Degree in which hospital Staff acknowledged your emotional needs
4. Response to concerns/complaints made during your stay
5. Effort to include you on decisions about your treatment
6. Your confidence that staff provided care in safe and accurate manner
Comments
(Describe good or bad experience)
J. OVERALL ASSESMENT OF HOSPITAL
Excellent
Good
Fair
Poor
Very Poor
N/A
5
4
3
2
1
5
4
3
2
1
N/A
1. Overall cheerfulness of hospital
2. How well staff worked together in care for you
3. Likelihood of you recommending Hind General Hospital to others
4. Overall rating of care given at Hind General Hospital
Have you used another hospital for inpatient care in the past two years?
Yes
No
What did you like best about your stay at Hind Hospital?
What did you like least about your stay at Hind Hospital?
If you would like a hospital representative to call you about your stay, please provide your name and a day time phone number
Thank you for your valuable assistance, please Click the submit button to send your CONFIDENTIAL survey to the Hind General Hospital.
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