AQI Olympic Anesthesia Patient Satisfaction Survey NEW

Olympic Anesthesia Patient Satisfaction Survey

At Olympic Anesthesia our patients are important to us and this survey is intended to help us determine what we are doing well and where we can improve. Please take a moment to tell us about your recent anesthesia experience. We will keep your responses private and only use them to better our practice. If you would rather take this survey on line please access it on our website: www.olympicanesthesia.com/patient/survey

Please note that St. Michael Medical Cntr. was formerly named Harrison Medical Center. Thank you for your time.

Question Title

1. Please tell us a few things about your recent procedure...

Name of Patient:

Name of Anesthesia Provider:

Date of Service and Name of Surgeon/OB Provider:

Question Title

2. What facility did your procedure take place at? (Please Check One)

Pacific Surgery Center- Poulsbo

The Doctor's Clinic Salmon Medical Center- Silverdale

Surgery Center of Silverdale

St. Michael Medical Cntr.- Bremerton Campus

St. Michael Medical Cntr.- Labor & Delivery

St. Michael Medical Cntr.- Orthopedics

St. Michael Medical Cntr.- Silverdale Campus

Question Title

3. During your visit with the anesthesia provider (before surgery) how satisfied were you with the amount of information you were given & the answers to your questions?

5 - Very Satisfied

4- Satisfied

3- Slightly Satisfied

2- Dissatisfied

1- Very Dissatisfied

Question Title

4. How satisfied were you with the response by the anesthesia team to your comfort and well-being?

5 - Very Satisfied

4 - Satisfied

3 - Slightly Satisfied

2 - Dissatisfied

1 - Very Dissatisfied

Question Title

5. How likely are you to recommend your ANESTHESIA PROVIDER(S) to a friend or family member?

5 - Very Likely

4 - Likely

3 - Slightly Likely

2 - Unlikely

1 - Very Unlikely

Question Title

6. How would you rate your overall ANESTHESIA experience?

5 - Best Anesthesia experience

4 - Above Average Anesthesia experience

3 - Average Anesthesia experience

2 - Below Average Anesthesia experience

1 - Worst Anesthesia experience

0- Not Applicable

Question Title

7. How satisfied were you with the ability of the anesthesia team to control your pain after surgery?

5 - Very Satisfied

4 - Satisfied

3 - Slightly Satisfied

2 - Dissatisfied

1 - Very Dissatisfied

Question Title

8. At DISCHARGE how would you rate your pain level? 0 = NO PAIN & 10 = Worst Pain Ever

1-2

3-4

5-6

7-8

9-10

1-2

3-4

5-6

7-8

9-10

Question Title

9. After you left the recovery room or returned home...

	No	Yes
Did you experience nausea?	Did you experience nausea? No	Did you experience nausea? Yes
Did you vomit at any time?	Did you vomit at any time? No	Did you vomit at any time? Yes

Question Title

10. Did you experience any unexpected events related to your anesthesia care?

Yes

If yes, please explain below. If you would like to speak to our staff about any concerns or questions please call us at 360-479-3657 or email at info@olympicanesthesia.com. Thank you for taking time to give us this valuable feedback.

Question Title

11. Internal use only (Not to be filled in by patient)

Needs Review

Review Complete