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Patient Care Survey

Care from Nurses

During this hospital stay, how often did nurses treat you with courtesy and respect?

During this hospital stay, how often did nurses listen carefully to you?

During this hospital stay, how often did nurses explain things in a way you could understand?

During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

Care from Doctors

During this hospital stay, how often did doctors treat you with courtesy and respect?

During this hospital stay, how often did doctors listen carefully to you?

During this hospital stay, how often did doctors explain things in a way you could understand?

Hospital Environment

During this hospital stay, how often were your room and bathroom kept clean?

During this hospital stay, how often was the area around your room quiet at night?

Hospital Experience

During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?

How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

During this hospital stay, did you have any pain?

During this hospital stay, how often did hospital staff talk with you about how much pain you had?

During this hospital stay, how often did hospital staff talk with you about how to treat your pain?

During this hospital stay, were you given any medicine that you had not taken before?

Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

Leaving the Hospital

Before leaving, do you intend to go directly to your own home, to someone else’s home, or to another health facility?

During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

Overall Rating of the Hospital
Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

Would you recommend this hospital to your friends and family?

About you

During this hospital stay, were you admitted to this hospital through the Emergency Room?

In general, how would you rate your overall health?

In general, how would you rate your overall mental or emotional health?

What is the highest grade or level of school that you have completed?

Are you of Spanish, Hispanic or Latino origin or descent?

What is your race? Please choose one or more.

What language do you mainly speak at home?

Please identify language

Overall comments:

Patient Survey Template Checklist

Created by: SafetyCulture Staff | Industry: Health Services | Downloads: 9

This patient survey template based on the HCAHPS Survey is designed to measure the quality of hospital care. Administered by hospital staff, this digital survey uses conditional logic to hide or display relevant succeeding questions based on precedent answers. This template utilizes failed items to help determine which areas in patient care need priority.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Patient Care Survey

Care from Nurses

During this hospital stay, how often did nurses treat you with courtesy and respect?

During this hospital stay, how often did nurses listen carefully to you?

During this hospital stay, how often did nurses explain things in a way you could understand?

During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

Care from Doctors

During this hospital stay, how often did doctors treat you with courtesy and respect?

During this hospital stay, how often did doctors listen carefully to you?

During this hospital stay, how often did doctors explain things in a way you could understand?

Hospital Environment

During this hospital stay, how often were your room and bathroom kept clean?

During this hospital stay, how often was the area around your room quiet at night?

Hospital Experience

During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?

How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

During this hospital stay, did you have any pain?

During this hospital stay, how often did hospital staff talk with you about how much pain you had?

During this hospital stay, how often did hospital staff talk with you about how to treat your pain?

During this hospital stay, were you given any medicine that you had not taken before?

Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

Leaving the Hospital

Before leaving, do you intend to go directly to your own home, to someone else’s home, or to another health facility?

During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

Overall Rating of the Hospital
Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

Would you recommend this hospital to your friends and family?

About you

During this hospital stay, were you admitted to this hospital through the Emergency Room?

In general, how would you rate your overall health?

In general, how would you rate your overall mental or emotional health?

What is the highest grade or level of school that you have completed?

Are you of Spanish, Hispanic or Latino origin or descent?

What is your race? Please choose one or more.

What language do you mainly speak at home?

Please identify language

Overall comments: