Hospital Patient Discharge Process Evaluation Form
Please provide your feedback on the discharge 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 the discharge process
1
2
3
4
5
Clarity of discharge instructions
1
2
3
4
5
Timeliness of discharge
1
2
3
4
5
Staff professionalism and courtesy
1
2
3
4
5
Were all your questions answered satisfactorily?
Yes
No
Additional comments or suggestions
Submit
Should be Empty: