Patient Satisfaction Survey Form - Asge

ADVERTISEMENT
Patient Satisfaction Survey
Dear Patient:
At
, we are committed to providing you with the best possible
healthcare. We are interested in knowing what you think about our services. You can help us evaluate our
performance by completing this brief (5 minute) survey regarding your visit.
Thank you for taking time to share your experience with us.
Date of your Procedure _______________ AM/PM (Versus Appointment Time ______)
very
very
poor
fair
good
N/A
Rating
poor
good
If you spoke to the facility by phone, how helpful was the
1
1
2
3
4
5
person you spoke with
2
Ease of scheduling your procedure
1
2
3
4
5
3
The ease of the check-in process
1
2
3
4
5
4
The comfort, cleanliness, and amenities of the facility
1
2
3
4
5
Clear and sufficient instructions on what to do and what to
5
1
2
3
4
5
expect before your procedure
The wait time in the endoscopy unit, compared to your
6
1
2
3
4
5
expectation
7
The courtesy and caring of your physician
1
2
3
4
5
8
The courtesy and caring of the nursing and support staff
1
2
3
4
5
9
Skills of assisting staff, for instance when starting your IV
1
2
3
4
5
10
Comfort level within the procedure room
1
2
3
4
5
Usefulness of the information provided about what was done
11
1
2
3
4
5
during your procedure
Clear and sufficient instructions on what to do and what to
12
1
2
3
4
5
expect after your procedure
Overall how would you rate the teamwork between the doctor,
13
1
2
3
4
5
nurses and other staff
14
Overall how satisfied were you with the procedure experience
1
2
3
4
5
 Y
 N
Was this your first visit as a patient to our facility?
 Y
 N
Likelihood of you recommending this facility to others?
Please add any comments you have regarding your experience today:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
urvey developed by the American Society for Gastrointestinal Endoscopy
S
2012
Patient Satisfaction Survey
Dear Patient:
At
, we are committed to providing you with the best possible
healthcare. We are interested in knowing what you think about our services. You can help us evaluate our
performance by completing this brief (5 minute) survey regarding your visit.
Thank you for taking time to share your experience with us.
Date of your Procedure _______________ AM/PM (Versus Appointment Time ______)
very
very
poor
fair
good
N/A
Rating
poor
good
If you spoke to the facility by phone, how helpful was the
1
1
2
3
4
5
person you spoke with
2
Ease of scheduling your procedure
1
2
3
4
5
3
The ease of the check-in process
1
2
3
4
5
4
The comfort, cleanliness, and amenities of the facility
1
2
3
4
5
Clear and sufficient instructions on what to do and what to
5
1
2
3
4
5
expect before your procedure
The wait time in the endoscopy unit, compared to your
6
1
2
3
4
5
expectation
7
The courtesy and caring of your physician
1
2
3
4
5
8
The courtesy and caring of the nursing and support staff
1
2
3
4
5
9
Skills of assisting staff, for instance when starting your IV
1
2
3
4
5
10
Comfort level within the procedure room
1
2
3
4
5
Usefulness of the information provided about what was done
11
1
2
3
4
5
during your procedure
Clear and sufficient instructions on what to do and what to
12
1
2
3
4
5
expect after your procedure
Overall how would you rate the teamwork between the doctor,
13
1
2
3
4
5
nurses and other staff
14
Overall how satisfied were you with the procedure experience
1
2
3
4
5
 Y
 N
Was this your first visit as a patient to our facility?
 Y
 N
Likelihood of you recommending this facility to others?
Please add any comments you have regarding your experience today:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
urvey developed by the American Society for Gastrointestinal Endoscopy
S
2012

Download Patient Satisfaction Survey Form - Asge

323 times
Rate
4.8(4.8 / 5) 19 votes
ADVERTISEMENT