Patient Perception of Care Survey - Ambulatory Infusion Center

Palmetto Infusion is pleased to have the opportunity to provide you with infusion therapy services. We appreciate your taking a few minutes to give us valuable feedback on meeting your needs and expectations in providing your infusion therapy. Your confidential comments and suggestions will help us improve our care. Thank you.

At which Infusion Center did you receive services?

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* 1. At which Infusion Center did you receive services?

How long have you been a patient of Palmetto Infusion Services?

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* 2. How long have you been a patient of Palmetto Infusion Services?

What was the date of your most recent service? (Optional)

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* 3. What was the date of your most recent service? (Optional)

Date of Service
What is the name of your physician who ordered your treatment? (Optional)

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* 4. What is the name of your physician who ordered your treatment? (Optional)

Which Therapy did you receive?

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* 5. Which Therapy did you receive?

Please tell us the name of your insurance provider. (Optional)

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* 6. Please tell us the name of your insurance provider. (Optional)

Please rate the following regarding the Infusion Center's ENVIRONMENT OF CARE.

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* 7. Please rate the following regarding the Infusion Center's ENVIRONMENT OF CARE.

  Excellent Very Good Good Poor Very Poor
Cleanliness of infusion clinic and facility
Privacy of infusion area
Noise control
Temperature control
Cleanliness of restroom facilities
Friendliness of office staff
Please rate the following PHARMACY AND PHYSICIAN SERVICES.

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* 8. Please rate the following PHARMACY AND PHYSICIAN SERVICES.

  Excellent Very Good Good Poor Very Poor N/A
Your Pharmacist was available for consultation (offered by phone if unavailable at infusion site).
Communication with your pharmacist was professional and helpful.
Your Palmetto Physician was knowledgeable regarding your therapy and diagnosis.
Your Palmetto Physician was professional in appearance and communications.
How well was your pain controlled (if applicable to your care).
Please rate the EQUIPMENT used during your visit.

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* 9. Please rate the EQUIPMENT used during your visit.

  Excellent Very Good Good Poor Very Poor
Equipment was clean and in good working order.
Please rate the service you received from our BUSINESS OFFICE.

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* 10. Please rate the service you received from our BUSINESS OFFICE.

  Excellent Very Good Good Poor Very Poor
Financial responsibilities were clearly explained.
Staff was knowledgeable about insurance coverage and benefits.
Staff communication was professional and courteous.
Please rate the NURSING SERVICES you received.

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* 11. Please rate the NURSING SERVICES you received.

  Excellent Very Good Good Poor Very Poor
Knowledge and technical ability of your nursing team.
Your nurse was responsive to your concerns and needs.
On the initial visit your nurse thoroughly explained what to expect.
Instructions and educational materials were clear.
Instructions on how to contact your Palmetto Clinical Team after hours were clear.
Please rate our BILLING/REIMBURSEMENT DEPARTMENT.

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* 12. Please rate our BILLING/REIMBURSEMENT DEPARTMENT.

  Excellent Very good Good Poor Very poor
Knowledge and professional communication with your billing department.
Billing statements were explained clearly.
Calls from reimbursement department were returned promptly and courteously.
Please rate your overall satisfaction with your experience with Palmetto Infusion Services.

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* 13. Please rate your overall satisfaction with your experience with Palmetto Infusion Services.

Did you experience any problems during your ambulatory infusion therapy? If yes, please explain.

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* 14. Did you experience any problems during your ambulatory infusion therapy? If yes, please explain.

How can we improve our services?

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* 15. How can we improve our services?

Do you have any suggestions to improve patient safety? If yes, please explain.

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* 16. Do you have any suggestions to improve patient safety? If yes, please explain.

Additional comments:

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* 17. Additional comments:

Would you recommend Palmetto Infusion Services to friends or family?

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* 18. Would you recommend Palmetto Infusion Services to friends or family?

Would you use Palmetto Infusion Services in the future?

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* 19. Would you use Palmetto Infusion Services in the future?

Would you like someone to contact you to discuss this survey?

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* 20. Would you like someone to contact you to discuss this survey?

Thank you for completing this survey. Your comments are important to us!

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