Emergency Department 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 received services in the Emergency Department
  • Answer all of the questions by checking the box to the left of your answer.



A. REGISTRATION

1. Was the registration process easy to complete?    Never
   Sometimes
   Usually
   Always

2. Was the manner of the person who registered you courteous, respectful, and sensitive?    Never
   Sometimes
   Usually
   Always

3. Was the waiting time before you were called to an Emergency Department room appropriate?    Never
   Sometimes
   Usually
   Always


B. NURSING STAFF

1. Was the manner of the nursing staff courteous, respectful, and sensitive?    Never
   Sometimes
   Usually
   Always

2. Did the nursing staff attend to your needs in a timely manner?    Never
   Sometimes
   Usually
   Always

3. Regarding the technical skills of the nursing staff, were they thorough, careful, and competent?    Never
   Sometimes
   Usually
   Always

4. Did the nursing staff keep you adequately informed and answer your questions?    Never
   Sometimes
   Usually
   Always

5. Was your privacy respected?    Never
   Sometimes
   Usually
   Always


C. PHYSICIAN

1. Was the manner of the Emergency Department Physician courteous, respectful, and sensitive?    Never
   Sometimes
   Usually
   Always

2. Did the physician keep you adequately informed and answer your questions?    Never
   Sometimes
   Usually
   Always

3. Was the staff thorough, careful, and competent?    Never
   Sometimes
   Usually
   Always

4. Did the physician spend adequate time with you?    Never
   Sometimes
   Usually
   Always


D. ENVIRONMENT

1. Was the area clean and free of clutter?    Never
   Sometimes
   Usually
   Always

2. Was the equipment in working order?    Never
   Sometimes
   Usually
   Always

3. Was the noise level in the area kept to a minimum?    Never
   Sometimes
   Usually
   Always

4. Was the room temperature comfortable?    Never
   Sometimes
   Usually
   Always


E. DISCHARGE

I. Did the staff explain the education and discharge instructions in a way you could understand?    Never
   Sometimes
   Usually
   Always

2. Were the follow up care instructions complete?    Never
   Sometimes
   Usually
   Always


F. OVERALL RATING OF HOSPITAL

Please answer the following questions about this visit to Pointe Coupee General Hospital.
Do not include any other hospital visits in your answers.

1. 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 visit?    0 Worst
   1
   2
   3
   4
   5
   6
   7
   8
   9
   10 Best

2. Would you recommend this hospital to your friends and family?    Never
   Sometimes
   Usually
   Always


G. ABOUT YOU

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

2. 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 than 4-year college degree

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

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


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

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

6. If you chose Some other language then enter it here:
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