Patient Satisfaction Survey Form

Patient Name: *

Date: *

Thank you for allowing us to provide care for you or your family member. We are interested in your ideas or opinion about our care to improve our services. Please take a moment to answer the following questions. Additional comments are welcome and can be recorded on the back of this form. If you need assistance in completing this form, please feel free to contact our office.

For questions 1 - 12, please check mark the appropriate box that describes your opinion.

I was satisfied with the care provided by the:

A. Nurse(s)

Excellent	Good	Fair	Poor
N/A

B. Physical Therapist

Excellent	Good	Fair	Poor
N/A

C. Occupational Therapist

Excellent	Good	Fair	Poor
N/A

D. Speech/Language Pathologist

Excellent	Good	Fair	Poor
N/A

E. Medical Social Worker

Excellent	Good	Fair	Poor
N/A

F. Home Health Aide(s)

Excellent	Good	Fair	Poor
N/A

2. I was involved in decision-making regarding my plan of care.

Yes

No

3. My opinion was considered in planning my care.

Yes

No

4. Staff discussed my discharge from the agency, and I was involved in Planning

Yes

No

5. Staff treated me, my family, my home and belongings with respect.

Yes

No

6. Staff explained my condition, rights and responsibilities, other procedures related to the care I received.

Yes

No

7. I was able to reach my nurse/therapist promptly and my phone calls were returned.

Yes

No

8. When I call the Agency, office staff is courteous and available and direct my call correctly.

Yes

No

9. I would use this Agency again.

Yes

No

10. I would recommend this Agency to friends and relatives.

Yes

No

11. Pain management was effective

Yes

No

11. Pain management was effective

Yes

No

12. The staff generally arrived as scheduled.

A. Nurse(s)

always

sometimes

never

not applicable

B. Physical Therapist

always

sometimes

never

not applicable

C. Occupational Therapist

always

sometimes

never

not applicable

D. Speech/Language Pathologist

always

sometimes

never

not applicable

E. Medical Social Worker

always

sometimes

never

not applicable

F. Home Health Aide(s)

always

sometimes

never

not applicable

Comments or suggestions for Agency and Patient Safety improvement:

What most impressed me about the Agency's care/services was:

Thank you for your valuable feedback. This confidential information will be used only in efforts to improve care/service.

I Would

Would not like to discuss my responses further.

Optional Signature of Person Completing Form

Date