Hospice Patient Satisfaction Survey
It can be filled out by the patient or his/her family/representatives. The final results will assist us in determining which services of the Hospice require improvement. The data collected from this survey will be analyzed as a group to ensure confidentiality and anonymity.
Please rate how satisfied are you with the following statements
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
N/A
the care you received from the health care provider?
1
2
3
4
5
the frequency of the health care provider’s visits?
6
7
8
9
10
the time the health care provider spent with you during visits/consultation?
11
12
13
14
15
the care received by you from the nurses?
16
17
18
19
20
the emotional support that was provided
21
22
23
24
25
by the nurses?
26
27
28
29
30
how quickly the nurses answered the buzzer?
31
32
33
34
35
the information were given to you about your
36
37
38
39
40
illness and treatment?
41
42
43
44
45
your involvement in decisions about their care?
46
47
48
49
50
the food service?
51
52
53
54
55
the cleanliness of the unit?
56
57
58
59
60
the level of noise?
61
62
63
64
65
the temperature of the unit?
66
67
68
69
70
the management of pain?
71
72
73
74
75
the management of other symptoms?
76
77
78
79
80
(nausea, vomiting, constipation, etc.)
81
82
83
84
85
the observance of your wishes
86
87
88
89
90
Overall, please rate the hospice
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
If you have anything you think should be done differently, please write below
Was the referral to the hospice appropriate?
Yes
No
Was the referral made in a timely manner?
Yes
No
Additional comments or questions
How long have you stayed here?
Less than 1 month
1-6 months
6-12 months
1-3 years
More than 3 years
Gender
Female
Male
Don't want to specify
Other
Name (Optional)
First Name
Last Name
Submit
Should be Empty: