This survey available for download in two formats:
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HOSPITAL DISCHARGE SURVEY
SURVEY INSTRUCTIONS
- You should fill out this survey only if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.
- Answer all the questions by checking the box next to your response.
HOSPITAL USE 1. Have you stayed in a hospital overnight since you left the hospital on {discharge date}? This means being admitted to a hospital floor (not just the emergency room). 1___ Yes 2___ No If YES, please fill out the table below for each hospital visit. List the hospital, date of arrival, and reason for each hospitalization.
2. Have you been to the emergency room since you left the hospital on {discharge date}? These would be emergency room visits that did not cause you to be admitted to the hospital (so you stayed in the emergency room the entire time and went home from the emergency room). 1___ Yes 2___ No If YES, please fill out the table below for each emergency room visit. List the hospital, date of arrival, and reason for each visit.
APPOINTMENTS These next questions are about any appointments you had after you left the hospital on {discharge date}. 3. Do you have a particular doctor's office, clinic, health center, or other place that you usually go to if you are sick or need advice about your health? 1___ Yes 2___ No 4. Since you left the hospital on {discharge date}, have you seen your medical provider, sometimes called a primary care provider (or someone in their office)? 1___ Yes 2___ No If YES, What date did you see this person? _______________________________________ DIAGNOSIS 5. During your hospital stay, the doctors and nurses may have told you the name of your primary diagnosis or main problem. Do you know what your main problem was? 1___ Yes 2___ No 3___ N/A, reason: _________________________________________________ If YES, Can you please list the name of your primary diagnosis or main problem? _____________________________________________________________________________ These next questions ask about your visit at {hospital name} from {admit date} to {discharge date}. YOUR HOSPITAL STAY 6. During this hospital stay, how often did nurses treat you with courtesy and respect? 1___ Never 7. During this hospital stay, how often did nurses listen carefully to you? 1___ Never 8. During this hospital stay, how often did nurses explain things in a way you could understand? 1___ Never 9. During this hospital stay, how often did doctors treat you with courtesy and respect? 1___ Never 10. During this hospital stay, how often did doctors listen carefully to you? 1___ Never 11. During this hospital stay, how often did doctors explain things in a way you could understand? 1___ Never 12. During this hospital stay, how often were your questions answered to your satisfaction? 1___ Never 13. How often did hospital staff listen to you when they decided the plan for your care? 1___ Never MEDICINES 14. During this hospital stay, were you told to take any medicine after you left the hospital? Include prescription and nonprescription medicines as well as any medicines you were already taking before your hospital stay. 1___ Yes 2___ No → If No, Go to Question 21 15. During this hospital stay, did hospital staff explain the purpose of each of the medicines you were to take at home? 1___ Yes 2___ No → If No, Go to Question 17 16. Was the explanation of each medicine's purpose easy to understand? 1___ Never 17. During this hospital stay, did hospital staff explain how much to take of each medicine and when to take it when you were at home? 1___ Yes 2___ No → If No, Go to Question 19 18. How often was their explanation of how and when to take each medicine easy to understand? 1___ Never 19. During this hospital stay, did hospital staff ask you to describe how much you would take of each medicine and when you would take it when you were at home? 1___ Yes 2___ No 20. During this hospital stay, did hospital staff tell you whom to call after you left the hospital if you had questions about your medicines? 1___ Yes 2___ No 21. During this hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital? 1___ Yes 2___ No 22. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? 1___ Yes 2___ No → If No, Go to Question 24 23. Were these written instructions easy to understand? 1___ Yes 2___ No WHEN YOU LEFT THE HOSPITAL 24. After you left the hospital, did you go directly to your own home, to someone else's home, or to another health facility? 1___ Own home 25. After you left the hospital, did someone from the hospital call you to check how you were doing? 1___ Yes 2___ No → If No, Go to Question 27 If YES, please tell me how much you agree with the following statement: 26. After the call, all of my questions about my medical care were answered. ___ Strongly disagree OVERALL RATING OF HOSPITAL 27. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? _________ (0-10) 28. Would you recommend this hospital to your friends and family? ___ Definitely no 29. Did you feel that your family and you were treated with respect? 1___ Yes 2___ No ABOUT YOU There are only a few remaining items left. 30. What is your age? 1___ 18-30 years 31. In general, how would you rate your overall health? 1___ Excellent 32. What is the highest grade or level of school that you have completed? 1___ Some elementary or high school but did not graduate 33. Are you of Spanish, Hispanic, or Latino origin or descent? 1___ No, not Spanish/Hispanic/Latino 34. How would you describe your race? Please choose one or more. 1___ White 35. What language do you mainly speak at home? 1___ English THANK YOU Please return the completed survey in the postage-paid envelope. |
