Basic Information

Please provide your visit details

Name

Enter your first name

Surname

Enter your last name

Case Number

Enter your patient case number

Date of Visit

Select the date of your hospital visit

Shift

When did you receive care?

Department

Which department are you rating?

Nursing Care

Rate your experience with our nursing team.

Professionalism & Skill

The skill and professionalism of the nursing staff.

Responsiveness

How quickly nurses responded to your needs.

Communication

How well nurses explained things to you.

Compassion & Friendliness

The friendliness and compassion of the nurses.

Pain Management

How well your pain was managed by the nursing team.

Appearance of Nurses

The professional appearance and cleanliness of the nursing staff.

Doctor Care

Rate your experience with your doctor.

Listening Skills

How well the doctor listened to your concerns.

Clarity of Explanations

How clearly the doctor explained your condition and treatment.

Confidence in Doctor

Your confidence in the doctor's skill and expertise.

Time Spent with You

The amount of time the doctor spent with you.

Housekeeping

Rate the cleanliness and comfort of your environment.

Cleanliness of Room

The overall cleanliness of your room and facilities.

Response to Requests

The responsiveness of housekeeping to any requests.

Staff Attitude

The attitude and professionalism of housekeeping staff.

Room Amenities

The quality and condition of room amenities (bed, call bells, TV, etc.).

Catering

Rate your experience with our food services.

Food Quality

The taste and quality of the meals provided.

Menu Variety

The variety and options available on the menu.

Meal Portion Size

The portion size of the meals you received.

Staff Service

The courtesy and efficiency of the catering staff.

Timeliness of Meals

How promptly meals were served.

Allied Health Workers

e.g. Physio, Dietitian, Social Worker, Wound Care

Professionalism

The professionalism of the allied health provider.

Clarity of Explanations

How well they explained your therapy or plan.

Quality of Treatment

The quality of care or therapy you received.

Coordination with Team

How well they coordinated with your other care providers.

Admin & Other Services

Rate your experience with administrative processes and other services.

Admission Process

The ease and efficiency of the admission process.

Billing Clarity

The clarity and accuracy of the billing information.

Helpfulness of Admin Staff

The helpfulness and courtesy of the administrative staff.

Security Staff

The professionalism and visibility of security personnel.

Laboratory Services

Your experience with lab tests and sample collection.

Overall Experience

Your general feedback about the hospital stay.

Hospital Atmosphere

The overall comfort and atmosphere of the hospital.

Overall Communication

How well the care team communicated with you and each other.

Overall Satisfaction

How would you rate your entire hospital experience?

Staff Recognition

Let us know about specific staff members (optional)

Staff Compliments

Name any staff member who provided excellent care

Staff Concerns

Name any staff member you had concerns about

Additional Feedback

Please share any other feedback

Additional Comments

Share your thoughts, suggestions, or any other feedback...

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