Room Ringer
Patient Survey
Date of Survey
-
Month
-
Day
Year
Date
Room Number
Patient's Name
First Name
Last Name
Were you able to speak to the patient on the phone?
Yes I was able to speak to the patient directly
No, i spoke to a family member in the room
No the phone was not answered
No, the patient was unavailable or had been discharged
Did the patient understand their plan of care?
Yes
No
Unsure
NA
Has the patient spoken to their doctor
Yes
No
Unsure
Has the patient spoken to friends or family?
Yes
No
Unsure
Did the patient have any requests? (select all that apply)
None
Pain assistance
Bathroom assistance
Other
Did the patient wish to recognize any of the staff
Yes
No
If you answered Yes above, please list names of staff and title if possible.
Please note any additional comments made.
Submit
Should be Empty: