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Patient Experience Survey
Patient Experience Survey
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Created by Qualaris Staff
Patient Experience
Table of Contents
Audit Form
Audit Form
Patient Experience Survey
Description
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Required
Observed Date
Unit
ED
ICU
Med-Surg
PACU
Rehab
Shift
AM
PM
Night
Patient Experience Survey Checklist
Mark all as...
Are all whiteboard items present & legible to you?
Yes
No
N/A
Do you understand your daily goal?
Yes
No
N/A
Did staff introduce themselves to you?
Yes
No
N/A
Are you satisfied with the doctors caring for you?
Yes
No
N/A
Are you satisfied with the nurses caring for you?
Yes
No
N/A
Are staff responding to calls bells/lights quickly?
Yes
No
N/A
Have staff visited/rounded hourly when you are awake?
Yes
No
N/A
Are your belongings within reach?
Yes
No
N/A
Is the call bell/light within reach?
Yes
No
N/A
Is your water pitcher full?
Yes
No
N/A
Are you receiving toileting assistance quickly when needed?
Yes
No
N/A
Is your pain controlled?
Yes
No
N/A
Are your medications being explained when given to you?
Yes
No
N/A
Are the medication side effects being described to you?
Yes
No
N/A
Are you comfortable with the explanations about your medications?
Yes
No
N/A
Are you satisfied with the cleanliness of your room?
Yes
No
N/A
Are you able to rest without noise disturbances?
Yes
No
N/A
Are you aware of our Quiet Kit?
Yes
No
N/A
Is the temperature of your room comfortable?
Yes
No
N/A
Has your discharge plan been discussed with you?
Yes
No
N/A
Have your questions and concerns about your discharge plan been addressed?
Yes
No
N/A
Have your needs been addressed appropriately?
Yes
No
N/A
