Hospital Discharge Planning Feedback Evaluation Form
Please provide your feedback on the discharge planning process to help us improve our services.
Patient Full Name
First Name
Last Name
Date of Discharge
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall Satisfaction with Discharge Planning
1
2
3
4
5
Clarity of Discharge Instructions
1
2
3
4
5
Timeliness of Discharge Process
1
2
3
4
5
Communication with Healthcare Team
1
2
3
4
5
Additional Comments or Suggestions
Submit
Should be Empty: