Outpatient Procedure
Excelsior Springs Hospital

Thank you for using the Outpatient Department at ESH. We realize that you have many choices available to you when making health care choices for your family. We appreciate the fact you chose our hospital and want to make sure your visit met or exceeded your expectations. Please take a moment to complete this brief survey.

Your thoughts will help us provide better service to all of our patients in the future!

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* 1. Please indicate in which procedure you were seen:

Endoscopy (EGD/Colonoscopy)

Infusion

Injection

Other (please specify)

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* 2. What was your overall opinion of the Outpatient Department?

Excellent

Very Good

Good

Fair

Poor

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* 3. Would you choose our Outpatient Department again?

Yes

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* 4. Would you recommend our Outpatient Department to your family and friends?

Yes

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* 5. The ease and convenience of scheduling your appointment was:

Excellent

Very Good

Good

Fair

Poor

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* 6. When scheduling your appointment, how often was the scheduler polite and respectful?

Always

Usually

Sometimes

Never

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* 7. After the registration process, your wait time to be seen by a nurse was:

Excellent

Very Good

Good

Fair

Poor

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* 8. After being seen by a nurse, your wait time to be seen by your doctor was:

Excellent

Very Good

Good

Fair

Poor

I did not see my doctor this visit

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* 9. During your visit in the Outpatient Department, how often did nurses treat you with courtesy and respect?

Always

Usually

Sometimes

Never

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* 10. During your visit in the Outpatient Department, how often did nurses listen carefully to you?

Always

Usually

Sometimes

Never

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* 11. During your visit in the Outpatient Department, how often did nurses explain things in a way you could understand?

Always

Usually

Sometimes

Never

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* 12. During your visit in the Outpatient Department, how often did your doctor treat you with courtesy and respect?

Always

Usually

Sometimes

Never

I did not see my doctor this visit

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* 13. During your visit in the Outpatient Department, how often did your doctor listen carefully to you?

Always

Usually

Sometimes

Never

I did not see my doctor this vist

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* 14. During your visit in the Outpatient Department, how often did your doctor explain things in a way you could understand?

Always

Usually

Sometimes

Never

I did not see my doctor this visit

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* 15. The cleanliness and comfort of the Outpatient Department was:

Excellent

Very Good

Good

Fair

Poor

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* 16. Adequate precautions were taken for your safety:

Always

Usually

Sometimes

Never

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* 17. During your visit in the Outpatient Department, how often did staff maintain your privacy?

Always

Usually

Sometimes

Never

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* 18. Please rate the services you received from the following departments:

	Excellent	Very Good	Good	Fair	Poor	N/A
Admitting/Registration	Admitting/Registration Excellent	Admitting/Registration Very Good	Admitting/Registration Good	Admitting/Registration Fair	Admitting/Registration Poor	Admitting/Registration N/A
Laboratory	Laboratory Excellent	Laboratory Very Good	Laboratory Good	Laboratory Fair	Laboratory Poor	Laboratory N/A
Radiology	Radiology Excellent	Radiology Very Good	Radiology Good	Radiology Fair	Radiology Poor	Radiology N/A
Cardiopulmonary	Cardiopulmonary Excellent	Cardiopulmonary Very Good	Cardiopulmonary Good	Cardiopulmonary Fair	Cardiopulmonary Poor	Cardiopulmonary N/A

FOR ENDOSCOPY PATIENTS ONLY:

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* 19. Your instructions prior to your procedure were:

Excellent

Very Good

Good

Fair

Poor

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* 20. Your instructions after your procedure were:

Excellent

Very Good

Good

Fair

Poor

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* 21. Your pain was adequately managed/treated:

Always

Usually

Sometimes

Never

No Pain

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* 22. Date of visit (optional)

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* 23. Contact information (optional)

Name

Phone Number

Email Address

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* 24. Gender identity (optional)

Male

Female

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* 25. Age (optional)

Under 18 years

18-30 years

31-45 years

46-65 years

66 and over

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* 1. Please indicate in which procedure you were seen:

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* 2. What was your overall opinion of the Outpatient Department?

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* 3. Would you choose our Outpatient Department again?

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* 4. Would you recommend our Outpatient Department to your family and friends?

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* 5. The ease and convenience of scheduling your appointment was:

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* 6. When scheduling your appointment, how often was the scheduler polite and respectful?

Question Title

* 7. After the registration process, your wait time to be seen by a nurse was:

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* 8. After being seen by a nurse, your wait time to be seen by your doctor was:

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* 9. During your visit in the Outpatient Department, how often did nurses treat you with courtesy and respect?

Question Title

* 10. During your visit in the Outpatient Department, how often did nurses listen carefully to you?

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* 11. During your visit in the Outpatient Department, how often did nurses explain things in a way you could understand?

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* 12. During your visit in the Outpatient Department, how often did your doctor treat you with courtesy and respect?

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* 13. During your visit in the Outpatient Department, how often did your doctor listen carefully to you?

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* 14. During your visit in the Outpatient Department, how often did your doctor explain things in a way you could understand?

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* 15. The cleanliness and comfort of the Outpatient Department was:

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* 16. Adequate precautions were taken for your safety:

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* 17. During your visit in the Outpatient Department, how often did staff maintain your privacy?

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* 18. Please rate the services you received from the following departments:

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* 19. Your instructions prior to your procedure were:

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* 20. Your instructions after your procedure were:

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* 21. Your pain was adequately managed/treated:

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* 22. Date of visit (optional)

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* 23. Contact information (optional)

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* 24. Gender identity (optional)

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* 25. Age (optional)

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* 26. Comments: