Patient Satisfaction SurveyPatient Satisfaction Survey

1. What is your Name and Medical Record Number (If you have it available)?

What is your Name and Medical Record Number (If you have it available)? Name
Medical Record Number

2. Did our staff introduce themselves in a professional/courteous manner?

Did our staff introduce themselves in a professional/courteous manner? Yes

3. Was the plan of care including frequency and duration of visits discussed with you before care began?

Was the plan of care including frequency and duration of visits discussed with you before care began? Yes

4. Were your questions on medical concerns and personal needs answered appropriately to your satisfaction?

Were your questions on medical concerns and personal needs answered appropriately to your satisfaction? Yes

5. Were the services provided designed to meet your individual needs?

Were the services provided designed to meet your individual needs? Yes

6. Was the rehabilitation program provided by PT, OT, and ST performed to your needs and satisfaction?

Was the rehabilitation program provided by PT, OT, and ST performed to your needs and satisfaction? Yes

7. Would you like to commend and name an employee for exemplary performance?

Would you like to commend and name an employee for exemplary performance? Yes

8. If you answered yes to the above question, who would you like to commend and why?

If you answered yes to the above question, who would you like to commend and why?

9. Please rate the performance of the following staff where applicable:

	Poor	Fair	Satisfactory	Very Good	Excellent
Registered Nurse	*Please rate the performance of the following staff where applicable: Registered Nurse Poor	Registered Nurse Fair	Registered Nurse Satisfactory	Registered Nurse Very Good	Registered Nurse Excellent
Nurse Assistant	Nurse Assistant Poor	Nurse Assistant Fair	Nurse Assistant Satisfactory	Nurse Assistant Very Good	Nurse Assistant Excellent
Physical Therapist	Physical Therapist Poor	Physical Therapist Fair	Physical Therapist Satisfactory	Physical Therapist Very Good	Physical Therapist Excellent
Occupational Therapist	Occupational Therapist Poor	Occupational Therapist Fair	Occupational Therapist Satisfactory	Occupational Therapist Very Good	Occupational Therapist Excellent
Speech Therapist	Speech Therapist Poor	Speech Therapist Fair	Speech Therapist Satisfactory	Speech Therapist Very Good	Speech Therapist Excellent
Registered Dietitian	Registered Dietitian Poor	Registered Dietitian Fair	Registered Dietitian Satisfactory	Registered Dietitian Very Good	Registered Dietitian Excellent
Medical Social Worker	Medical Social Worker Poor	Medical Social Worker Fair	Medical Social Worker Satisfactory	Medical Social Worker Very Good	Medical Social Worker Excellent

10. Please make any suggestions or recommendations:

Please make any suggestions or recommendations:

Patient Satisfaction Survey
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