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In-Patient: Patient Experience Feedback Survey
*
1.
Select the Hospital site you visited:
(Required.)
Alexandra Hospital Ingersoll
Tillsonburg District Memorial Hospital
2.
Did Nurses treat you with courtesy and respect?
Always
Usually
Sometimes
Never
3.
Did Nurses listen carefully to you?
Always
Usually
Sometimes
Never
4.
Did Nurses explain things in a way that you could understand?
Always
Usually
Sometimes
Never
5.
After you pressed the call button, did you get help as soon as you needed it?
Always
Usually
Sometimes
Never
I never pressed the call button.
6.
Did Doctors treat you with courtesy and respect?
Always
Usually
Sometimes
Never
7.
Did Doctors listen carefully to you?
Always
Usually
Sometimes
Never
8.
Did Doctors explain things in a way that you could understand?
Always
Usually
Sometimes
Never
9.
Were your room/bathroom kept clean?
Always
Usually
Sometimes
Never
10.
Before giving you any new medication, did a Docotor or Nurse explain what the medication was for and describe possible side effects?
Always
Usually
Sometimes
Never
Not applicable
11.
Did you get all the information you needed about your condition and treatment?
Always
Usually
Sometimes
Never
12.
Did you get the support you needed to help you with any anxieties, fears or worries you had during this hospital stay?
Always
Usually
Sometimes
Never
Not applicable
13.
Were your family or friends involved as much as you wanted in decisions about your care and treatment?
Always
Usually
Sometimes
Never
I did not want them to be involved
I did not have family or friends who could be involved
14.
Before you left the hospital did you have a clear understanding of all of your prescribed medications, including those you were taking before your hospital stay?
Completely
Quite a bit
Partly
Not at all
Not appliable
*
15.
Did you receive enough information from hospital team members about what to do if you were worried about your condition or treatment after you left the hospital?
(Required.)
Completely
Quite a bit
Partly
Not at all
16.
Canadians come from different ethnic backgrounds, religious beliefs and gender identifications. At our hospital were strive to treat everyone equally, fairly and appropriately. Have you experienced any challenges in these areas? If so, your input would be appreciated.
No
Yes
If YES, please explain and offer your suggestions on how we can improve:
17.
Did you have any difficulty getting your needs met for mobility, hearing, vision or any other challenges you may have?
No
Yes
Not applicable
If YES, please describe your challenges.
18.
Overall, do you feel you were helped by your hospital stay?
1. Not at all
2
3
4
5
6
7
8
9
10. Helped Completely
1. Not at all
2
3
4
5
6
7
8
9
10. Helped Completely
19.
Overall, I had a very:
1. Poor experience
2
3
4
5
6
7
8
9
10. Good experience
1. Poor experience
2
3
4
5
6
7
8
9
10. Good experience
20.
Is there anything else you would like to say about your experience or is there a staff member or group that you would like to recognize for providing exceptional care or service?
Yes
No
If YES, please specify below:
