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Outpatient Surgery Experience
Outpatient Surgery Experience
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Created by Qualaris Staff
Critical Access Hospital
Case Management
Table of Contents
Audit Form
Audit Form
Outpatient Surgery Experience
Required
Observed Date
Patient comments
Do not enter protected health information (PHI)
Rate the facility
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Outpatient Surgery Experience Checklist
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Before Your Procedure
Did you recieve all of the information you needed prior to arrival?
Yes
No
Was the information you recieved easy to understand?
Yes
No
About the facility and staff
Did the check-in process run smoothly?
Yes
No
Was the facility clean?
Yes
No
Did the clerks and receptionists treat you with courtesy and respect?
Yes
No
Did the doctors treat you with courtesy and respect?
Yes
No
Did the nurses treat you with courtesy and respect?
Yes
No
Did the doctors make sure you were as comfortable as possible?
Yes
No
Did the nurses make sure you were as comfortable as possible?
Yes
No
Communications about your procedure
Did the doctors explain your procedure in a way that was easy to understand?
Yes
No
Did the nurses explain your procedure in a way that was easy to understand?
Yes
No
Were you given anesthesia?
Yes
No
Did anyone explain the possible side efects of anesthesia in a way that was easy to understand?
Yes
No
N/A
Before you left were you given written discharge instructions?
Yes
No
Did your doctor or anyone from the facility prepare you for what to expect during your recovery?
Yes
No
Would you recommend this facility to your friends and family?
Yes
No
