Patient Interview Checklist

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Patient Interview

• 1. How was everything when you entered the room? Did you feel everything was clean or up to your standards?

  Yes

  No

  N/A

• 2. Have you been satisfied with your housekeeper cleaning your room?

  Yes

  No

  N/A

• 3. Did your housekeeper introduce them-self by name when they entered the room?

  Yes

  No

  N/A

• 4. Did you see if your housekeeper sanitized their hands?

  Yes

  No

  N/A

• 5. Do you mind if I check your bathroom?

  Yes

  No

  N/A

• 6. Was this compliant? Is there anything we could have done better to make your stay more pleasant? Is there anything you need before I leave?<br><br>Anything pertaining to nursing or another department- please use the call button in the room to communicate

  Yes

  No

  N/A

• Thank you for taking the time to visit with me. Your input is vital to our patient care.

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