Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Scoring: 1= Very Poor; 2= Poor; 3= Fair; 4= Good; 5= Very Good
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1. How would you rate the communication between you, your nurse, doctor, or others? How have we kept you informed/involved with your care?
- 1= Very Poor
- 2= Poor
- 3= Fair
- 4= Good
- 5= Very Good
- N/A
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Comments Question 1:
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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?
- 1= Very Poor
- 2= Poor
- 3= Fair
- 4= Good
- 5= Very Good
- N/A
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Comments Question 2:
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3. How have we satisfied your personal needs? Is the Guest Service book within patient's reach?
- 1= Very Poor
- 2= Poor
- 3= Fair
- 4= Good
- 5= Very Good
- N/A
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Comments Question 3:
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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.
- 1= Very Poor
- 2= Poor
- 3= Fair
- 4= Good
- 5= Very Good
- N/A
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Comments Question 4:
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5. How would you rate the care we have given you?
- 1= Very Poor
- 2= Poor
- 3= Fair
- 4= Good
- 5= Very Good
- N/A
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Comments Question 5:
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6. What can we do to provide you with level 5 care?
- 1= Very Poor
- 2= Poor
- 3= Fair
- 4= Good
- 5= Very Good
- N/A
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Comments Question 6:
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Overall Comments:
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Department Leader Signature
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Auditors Signature
