Inpatient Satisfaction Survey

Source: http://www.hcahpsonline.org/,
Centers for Medicare and Medicaid Services,
Baltimore, MD, June 26, 2011
 
 
SURVEY INSTRUCTIONS
  • Complete this survey only if you were the patient during the hospital stay.
  • Answer all of the questions by checking the box to the left of your answer.
  • You are sometimes told to skip over some questions in this survey. When this happens, you will see a note that tells you what question to answer next, like this:
    O Yes
    O No (If No, Go to Question 1)



YOUR CARE FROM NURSES

1. During this hospital stay how often did the nurses treat you with courtesy and respect?    Never
   Sometimes
   Usually
   Always

2. During this hospital stay, how often did the nurses listen carefully to you?    Never
   Sometimes
   Usually
   Always

3. During this hospital stay, how often did the nurses explain things in a way you could understand?    Never
   Sometimes
   Usually
   Always

4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?    Never
   Sometimes
   Usually
   Always
   I never pressed the call button


YOUR CARE FROM DOCTORS

5. During this hospital stay, how often did the doctors treat you with courtesy and respect?    Never
   Sometimes
   Usually
   Always

6. During this hospital stay how often did the doctors listen carefully to you?    Never
   Sometimes
   Usually
   Always

7. During this hospital stay, how often did the doctors explain things in a way that you could understand?    Never
   Sometimes
   Usually
   Always


THE HOSPITAL ENVIRONMENT

8. During this hospital stay how often were your room and bathroom kept clean?    Never
   Sometimes
   Usually
   Always

9. During this hospital stay, how often was the area around your room kept quiet at night?    Never
   Sometimes
   Usually
   Always


YOUR EXPERIENCES IN THIS HOSPITAL

10. During this hospital stay did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?    Never
   Sometimes
   Usually
   Always

11. How often did you get help in getting to the bathroom or in using the bedpan as soon as you wanted?    Never
   Sometimes
   Usually
   Always

12. During this hospital stay, did you need medicine for pain?    Yes
   No (If No, Go to Question 15)

13. During this hospital stay, how often was your pain well controlled?    Never
   Sometimes
   Usually
   Always

14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?    Never
   Sometimes
   Usually
   Always

15. During this hospital stay, were you given any medicine that you had not taken before?    Yes
   No (If No, Go to Question 18)

16. Before giving you any new medicine, how often did the hospital staff tell you what the medicine was for?    Never
   Sometimes
   Usually
   Always

17. Before giving you any new medicine, how often did the hospital staff describe possible side effects in a way you could understand?    Never
   Sometimes
   Usually
   Always


WHEN YOU LEFT THE HOSPITAL

18. After you left the hospital, did you go to your own home, to someone else`s home, or to another health facitify?    Own home
   Someone else`s home
   Another facility

19. During this hospital stay did doctors, nurses, or other hospital stafftalk with you about whether you would have the help you needed when you left the hospital?    Yes
   No

20. During this hospital stay, did you get information in writing about what symptoms or health problems to look for after you left the hospital?    Yes
   No


OVERALL RATING OF HOSPITAL

Please answer the following questions about your stay at Pointe Coupee General Hospital.
Do not include any other hospital stays in your answers.

21. Using any number 0 to 10, where 0 is the worst hospital possible and 10 the best hospital possible, what number would you use to rate this hospital during your stay?    0 Worst hospital possible
   1
   2
   3
   4
   5
   6
   7
   8
   9
   10 Best hospital possible

22. Would you recommend this hospital to your friends and family?    Definitely No
   Probably No
   Probably Yes
   Definitely Yes


ABOUT YOU

23. In general, how would you rate your overall health?    Excellent
   Very Good
   Good
   Fair
   Poor

24. What is the highest grade or level of school that you have completed?    8th grade or less
   Some high school, but did not graduate
   High school graduate or GED
   Some college or 2-year degree
   4-year college graduate
   More than4-year college degree

25. Are you of Spanish, Hispanic, or Latino origin or descent?    No, not Spanish/Hispanic/Latino
   Yes, Puerto Rican
   Yes, Mexican, MexicanAmerican, Chicano
   Yes, Cuban
   Yes, other Spanish/Hispanic/Latino

26. What is your race? Please choose one or more.

Caucasian
African-American
Asian
Native American or other Pacific Islander
American Indian or Alaska Native

27. What language do you mainly speak at home?    English
   Spanish
   Chinese
   Russian
   Vietnamese
   Some other language

28. If you chose some other language then type it here:
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