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Hospital Discharge Survey
1.
Are you completing this survey on behalf of
Yourself
As a family member or carer
Yourself
As a family member or carer
2.
Which ward were you discharged from?
3.
Did you have an expected or predicted discharge date?
Yes
No
Not sure
Yes
No
Not sure
4.
Have you been waiting beyond this date, if so, how long?
5.
After being admitted to hospital, were you given a copy of the 'One Step Closer to Home' booklet?
Yes
No
Not sure
Yes
No
Not sure
6.
Did you feel involved in decisions made for your discharge from hospital?
Yes
No
Yes
No
(please specify)
7.
Were you involved in your care plan?
(a care plan is the document that outlines your assessed health and social care needs and how you will be supported)
Yes
No
Not sure
Yes
No
Not sure
(please specify)
8.
Did you have the opportunity to discuss with a member of staff any worries or fears about your discharge?
Yes
No
Not sure
Yes
No
Not sure
(please specify)
9.
On the day of discharge were you given a contact number to call if you had any concerns?
Yes
No
Not sure
Yes
No
Not sure
10.
How would you rate your discharge from hospital
Very good
Good
Fair
Poor
Very poor
Don't know/not sure
Very good
Good
Fair
Poor
Very poor
Don't know/not sure
(Please explain your answer)
11.
How long did you wait in the discharge lounge before you left?
Less than one hour
One to two hours
Two to three hours
Three hours or more
Less than one hour
One to two hours
Two to three hours
Three hours or more
(please specify)
12.
Were you offered any refreshments while you waited for discharge if it was delayed?
Yes
No
N/A
Yes
No
N/A
(please explain)
13.
Were you treat with kindness and compassion by the staff in the discharge lounge?
Yes
No
Not sure
Yes
No
Not sure
(please explain)
14.
Overall, how happy were you with the care you received in the discharge lounge?
Very good
Good
Fair
Poor
Very poor
Don't know/not sure
Very good
Good
Fair
Poor
Very poor
Don't know/not sure
(please explain)
15.
Anything else not covered about Hospital Discharge you would like to tell us about.
Information about you
16.
What is your postcode?
17.
What is your age
18-24
25-34
35-44
45-54
55-64
65+
18.
What is your gender
Woman
Man
Non-Binary
Other
Prefer not to say
19.
What is your racial or ethnic identity?
Black, Black British: Any other Black / British British background
Arab
Asian or Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Pakistan
Asian/Asian British: Any other Asian/Asian British background
Black/Black British: African
Black/Black British: Caribbean
Black/Black British: Any other Black/Black British background
Mixed/Multiple ethnic groups: Asian and White
Mixed/Multiple ethnic groups: Black African and White
Mixed/Multiple ethnic groups: Black Caribbean and White
Mixed/Multiple ethnic groups: Any other Mixed/Multiple ethnic group background
White: British/English/Northern Irish/Scottish/Welsh
White: Irish
White: Gypsy/ Traveller/Irish Traveller
White: Roma
White: Any other White background
Prefer not to say
Other please specify
Other (please specify)
20.
Do you consider yourself to be a carer?
Yes
No
Prefer not to say
Yes
No
Prefer not to say
21.
Do you have a disability or long-term condition?
Yes
No
Prefer not to say
Yes
No
Prefer not to say
