Collect feedback with a patient survey template

Patient Survey Template

This Patient Survey Template based on the HCAHPS Survey helps you to measure the quality of hospital care. Conducted by hospital staff, this digital survey works with conditional logic to hide or present relevant succeeding questions based on earlier answers. This template uses failed items to help you decide which areas in patient care require priority.

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Preview of the template

Patient Care Survey

Care from Nurses

Throughout this hospital stay, how often did nurses treat you with kindness and respect?

Throughout this hospital stay, how often did you get help as soon as you needed it, after you pushed the call button?

Throughout this hospital stay, how often did nurses listen attentively to you?

Throughout this hospital stay, how often did nurses explain matters in a way you could understand?

Care from Doctors

Throughout this hospital stay, how often did doctors treat you with kindness and respect?

Throughout this hospital stay, how often did doctors explain matters in a way you could understand?

Throughout this hospital stay, how often did doctors listen attentively to you?

Hospital Environment

Throughout this hospital stay, how often were your room and bathroom held clean?

Throughout this hospital stay, how often was the range around your room quiet at night?

Hospital Experience

Throughout this hospital stay, did you require assistant from nurses or other hospital workers when getting to the bathroom or in using a bedpan?

Throughout this hospital stay, did you feel any pain?

Throughout this hospital stay, were you given any medicine that you never took before?

Leaving the Hospital

Before leaving, do you plan to go straight to your own home, to someone else’s home, or to another health facility?

Overall Rating of the Hospital

On a scale from 0 to 10, (0-the worst hospital possible; 10-the best hospital possible) how would you rate this hospital during your stay?

Would you suggest this hospital to friends and family?

About you

Throughout this hospital stay, were you admitted to here through the emergency room?

In general, how would you rank your overall mental or emotional health?

How would you rate your overall health?

Any comments?

This template was downloaded 4 times

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.