Patient Satisfaction Survey Form

We were privileged to participate in your care. We are interested in rendering quality care to our clients and would appreciate your input by answering the following questions. Your evaluation will allow us to be more responsive to future client/family needs.

1. How satisfied are you with the visit you received today? On a scale of 1-5, 5 being the best.

What can we do better?

2. Were you notified that you were to receive an initial home visit in a timely manner?

Yes

3. What services(s) did you receive from the Agency? (select all that apply)

Nursing	Physical Therapy	Occupational Therapy	Speech Therapy
Home Health Aide	Homemaking/Chore Service	Medical Social Worker

4. Did your admitting professional give you the telephone number and contact person at the agency in case you had any questions or concerns, including afterhours information?

Yes

5. Did you participate in your plan of care?

Yes

6. Did you receive information on your Bill of Rights including the State Hotline number to call if you have any complaints?

Yes

7. Did the agency admitting clinician present a professional appearance?

Yes

8. Did the clinician wear a name tag and introduce himself/herself as a representative of the agency and explain his/her role?

Yes

9. Did the clinician leave a folder with information about your care in your home?

Yes

10. Did you understand the services that your doctor ordered?

Yes

11. Did the staff keep you informed of the date of your next visit and the frequency of visits?

Yes

12. Did the nurse take your temperature, pulse, respirations, and blood pressure?

Yes

13. Did the staff wash their hands before and after caring for you?

Yes

14. Did the nurse teach/talk to you about: Your medications?

Yes

Signs and Symptoms to report to the doctor?

Yes

Wound Care (if applicable)?

Yes

Plans for discharge (if applicable)?

Yes

15. If you had therapy, were exercise instructions given to you in a clear, written manner that you could easily understand?

Yes

N/A

16. Did you feel the nurse answered your questions appropriately?

Yes

17. Did you feel that you were discharged appropriately?

Yes

18. Would you use the services of the Agency in the future?

Yes

19. Please provide the name and details of any staff member that you would like to recognize in the comments below.

Comments/Suggestions

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