Patient Satisfaction Post-Discharge Assessment Form
Please help us improve our services by sharing your experience after your recent discharge. Your feedback is confidential and highly valued.
Patient Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department/Unit of Care
*
Please Select
Internal Medicine
Surgery
Pediatrics
Maternity
Emergency
Other
How would you rate your overall experience with our healthcare facility?
*
1
2
3
4
5
Please rate the following aspects of your hospital stay:
*
Rows
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
Quality of medical care
1
2
3
4
5
Friendliness of staff
6
7
8
9
10
Clarity of discharge instructions
11
12
13
14
15
Timeliness of discharge process
16
17
18
19
20
Cleanliness of room and facilities
21
22
23
24
25
Did you feel you received enough information about your medications and follow-up care?
*
Yes, completely
Partially
No, not enough
Were your questions and concerns addressed before discharge?
*
All of them were addressed
Some were addressed
None were addressed
Was your discharge process handled efficiently?
*
Yes, very efficient
Somewhat efficient
Not efficient
Would you recommend our healthcare facility to others?
*
Yes
No
Not sure
Additional comments or suggestions
Submit Feedback
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