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PATIENT SATISFACTION SURVEY
Please take a few minutes and tell us how we are doing. We appreciate your valuable time and comments.All your responses will be held confidential.
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For questions 1-10, please choose a number that best describes your opinion.
I was satisfied with the care provided by the nurse
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I was satisfied with the care provided by the Physical Therapist
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I was satisfied with the care provided by the Occupational Therapist
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I was satisfied with the care provided by the Speech/Language Pathologist
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I was satisfied with the care provided by the Medical Social Worker
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I was satisfied with the care provided by the Certified Home Health Aide
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I was satisfied with the care provided by the Registered Dietician
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I was involved in decision-making regarding my plan of care.
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
My opinion was considered in the planning of discharge.
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
The staff treated me, my family, my home and belongings with respect.
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
The staff explained my conditions, rights and responsibilities,and procedures related to the care I received.
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
The staff generally arrived as scheduled.
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I was able to reach my nurse/therapist promptly and my phone calls were returned.
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
When I called the agency, the office staff was courteous,available and directed my calls promptly
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I would use this agency again.
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
I would recommend this agency to friends and relatives.
STRONGLY DISAGREE
1
2
3
4
5
STRONGLY AGREE
Clear selection
Suggestions for improvement/additional comments:
Your answer
What most impresses me about the agency’s care/ service was:
Your answer
Thank you for your valuable feedback. This is confidential and will be used only in efforts to improve care / services.
I would like to discuss my responses further:
Yes
No
Clear selection
NAME (optional)
Your answer
EMAIL ADDRESS (optional)
Your answer
TELEPHONE NUMBER (optional)
Your answer
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