Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Scoring: 1= Very Poor; 2= Poor; 3= Fair; 4= Good; 5= Very Good

  • 1. How would you rate the communication between you, your nurse, doctor, or others? How have we kept you informed/involved with your care?

  • Comments Question 1:

  • 2. How has your pain ben managed? What is your pain rated now? What is your pain goal? Is the pain box in use & currently updated?

  • Comments Question 2:

  • 3. How have we satisfied your personal needs? Is the Guest Service book within patient's reach?

  • Comments Question 3:

  • 4. How has our timeliness & friendliness been with regard to the call light? Press the call button & time how long it takes to be answered. Ask for help in the room. See how long it takes RN,CNA to respond.

  • Comments Question 4:

  • 5. How would you rate the care we have given you?

  • Comments Question 5:

  • 6. What can we do to provide you with level 5 care?

  • Comments Question 6:

  • Overall Comments:

  • Department Leader Signature

  • Auditors Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.