Template Information
Form used to round on patients
Category: health-services
Template Questions
- Scoring: 1= Very Poor; 2= Poor; 3= Fair; 4= Good; 5= Very Good
- 1. How would you rate the communication between you, your nurse, doctor, or others? How have we kept
- 2. How has your pain been managed? What is your pain rated now? What is your pain goal? Is the pain b
- 3. How have we satisfied your personal needs? Is the Guest Service book within patient's reach?
- 4. How has our timeliness & friendliness been with regard to the call light? Press the call button &
- 5. How would you rate the care we have given you?
- 6. What can we do to provide you with level 5 care?
- Patient Name
- Question 1
- Question 2
- Question 3
- Question 4
- Question 5
- Overall Comments
- Department Leader Signature
- Auditors Signature