Login
Try for Free
Home
Patient Experience Survey
Patient Experience Survey
Copy Link
Created by Qualaris Staff
Patient Experience
Table of Contents
Audit Form
Audit Form
Patient Experience Survey
Description
Show More
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
January
February
March
April
May
Sun
Mon
Tue
Wed
Thu
Fri
Sat
27
28
29
30
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1
2
3
4
5
6
7
