Inpatient Patient Interview

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Patient Interview

  Date

• Program, Name, Date of Admission

  Yes

  No

  N/A

• Is this your first admission to the hospital? Number of previous admissions?

  Yes

  No

  N/A

• Were you informed of and given a copy of your rights upon admission?

  Yes

  No

  N/A

• Have you seen where the Patients' Rights are posted?

  Yes

  No

  N/A

• Do you feel you have access to MHLS and/or an advocate or other peer support?

  Yes

  No

  N/A

Treatment by Staff

• Have interactions with staff been respectful?

  Yes

  No

  N/A

• Doctors

  Yes

  No

  N/A

• Nurses

  Yes

  No

  N/A

• Social workers

  Yes

  No

  N/A

• Aides

  Yes

  No

  N/A

• Environmental Services

  Yes

  No

  N/A

• Dietary Services

  Yes

  No

  N/A

Treatment Planning

• Have you been involved with your treatment planning?

  Yes

  No

  N/A

• Do you know your treatment goals?

  Yes

  No

  N/A

• Have you been involved with your discharge planning?

  Yes

  No

  N/A

• If you requested, have family or friends been involved in your treatment and discharge planning?

  Yes

  No

  N/A

Treatment/Program Activities

• Have the group activities been interesting and helpful

  Yes

  No

  N/A

• Are the activities focused on your treatment goals (ie medication compliance, MICA)

  Yes

  No

  N/A

Physical Setting and Amenities

• Are your surroundings on the unit comfortable?

  Yes

  No

  N/A

• Do you have adequate linens and towels?

  Yes

  No

  N/A

• Do you have a secure place to store your belongings?

  Yes

  No

  N/A

• Is there a comfortable setting for visitors?

  Yes

  No

  N/A

• Is the food to your liking?

  Yes

  No

  N/A

Special Procedures

• Have you received any special procedures such as ECT?

  Yes

  No

  N/A

• What was your experience?

  Yes

  No

  N/A

• Any additional comments

  Yes

  No

  N/A