Patient Rounding Form - All rooms

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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?

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

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

• 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.

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

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

3 MSU Room # 3.501

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.502

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.503

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.504

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.505

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.506

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.507

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.508

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.509

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.524

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

3 MSU Room # 3.527

• Patient Name

• Question 1

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 2

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 3

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 4

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Question 5

  Select 1= Very Poor 2= Poor 3= Fair 4= Good 5= Very Good N/A

  • 1= Very Poor
  • 2= Poor
  • 3= Fair
  • 4= Good
  • 5= Very Good
  • N/A

• Overall Comments

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