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
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.