Patient Satisfaction Self Assessment Patient Satisfaction Self Assessment Question Title * 1. Contact Information Name Practice Field of Practice EHR Vendor (if using paper, please type N/A) Daily Patient Panel Number of non-Physician Staff Staff Titles or Positions Question Title * 2. Our patients can schedule appointments readily and easily. Strongly Disagree Disagree Agree Strongly Agree Question Title * 3. Our office responds to patients' telephonic inquiries in a timely manner. Strongly Disagree Disagree Agree Strongly Agree Question Title * 4. Our office/practice contacts patients to remind them of upcoming appointments or tests. Strongly Disagree Disagree Agree Strongly Agree Question Title * 5. Patients see their provider within fifteen minutes of their scheduled appointment time. Strongly Disagree Disagree Agree Strongly Agree What is the average wait time in your office? Question Title * 6. Providers in our office ensure that patients fully understand the information they are provided. Strongly Disagree Disagree Agree Strongly Agree If you selected Disagree or Strongly Disagree, please explain why this is the case. Question Title * 7. Our office appropriately provides and receives information pertaining to patients' medical history. Strongly Disagree Disagree Agree Strongly Agree Question Title * 8. Providers in our office treat patients with dignity and respect. Strongly Disagree Disagree Agree Strongly Agree Question Title * 9. Providers in our practice spend sufficient time to adequately understand and address patient concerns. Strongly Disagree Disagree Agree Strongly Agree Question Title * 10. Our practice has in place, adequate protocol to monitor and track patients' test results. Strongly Disagree Disagree Agree Strongly Agree Question Title * 11. When discussing treatment (including medication) options, patients are provided with comprehensive information regarding the risks and benefits of each treatment and are able to make informed decisions. Strongly Disagree Disagree Agree Strongly Agree Question Title * 12. I believe my patients understand the information (how, when, why) they are given regarding their prescriptions. Strongly Disagree Disagree Agree Strongly Agree Question Title * 13. Our providers discuss with patients, their preferences regarding the sharing of protected health information. Strongly Disagree Disagree Agree Strongly Agree Question Title * 14. The front desk staff in our office is knowledgeable, courteous and professional. Strongly Disagree Disagree Agree Strongly Agree Question Title * 15. Providers in our office discuss with patients, the importance of a healthy diet, exercise, prevention and patient specific healthcare goals. Strongly Disagree Disagree Agree Strongly Agree Question Title * 16. Our practice offers patients direction with regard to where to obtain tests and/or treatments that cannot be done in our office. Strongly Disagree Disagree Agree Strongly Agree Question Title * 17. At every visit, a medication reconciliation (including OTC medications/supplements) is completed and documented. Strongly Disagree Disagree Agree Strongly Agree Question Title * 18. Providers in our office inquire as to whether patients have experienced feelings of sadness, emptiness, depression or worry/stress? Strongly Disagree Disagree Agree Strongly Agree Question Title * 19. Please provide any additional information about your practice that you feel is relevant to the development of a patient satisfaction performance improvement plan. Done