Maternity Ward Discharge Feedback Form
Please share your experience with the maternity ward discharge process to help us improve our services.
Patient's Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to the Patient
*
Mother
Spouse/Partner
Parent/Guardian
Other
How would you rate your overall experience with the discharge process?
*
1
2
3
4
5
Please rate the following aspects of your discharge experience:
*
Rows
Very Unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied
Friendliness of staff
1
2
3
4
5
Clarity of discharge instructions
6
7
8
9
10
Responsiveness to questions
11
12
13
14
15
Cleanliness of the ward
16
17
18
19
20
Privacy and comfort
21
22
23
24
25
Did you receive clear instructions regarding post-discharge care for yourself and your baby?
*
Yes, completely clear
Somewhat clear
Not clear
Were you informed about who to contact in case of questions or emergencies after discharge?
*
Yes
No
Did you feel ready and confident to go home with your baby at the time of discharge?
*
Yes
No
What aspects of the discharge process did you find most helpful?
Do you have suggestions for improvement or additional comments?
Submit Feedback
Should be Empty: