Kindly complete this feedback form and click "Submit". We assure you that every complaint will be acted upon professionally and in a strictly confidential manner.
يرجى إكمال هذا نموذج الملاحظات وانقر على زر "أرسل". نحن نؤكد لكم أن كل شكوى سيتم البت فيها مهنياً وبطريقة سرية للغاية.
Type of Feedback:
*
Suggestion اقتراح
Compliment ثناء
Complaint شكوى
Patient information: معلومات المريض
Full Name: الاسم بالكامل
*
Medical Record No: رقم السجل الطبي
Mobile Number: رقم الهاتف المتحرك
*
Home phone no: رقم هاتف المنزل
Email: البريد الالكتروني
Personal information (if other than patient): المعلومات الشخصية ( في حال وجود شخص آخر غير المريض )
Full Name: الاسم بالكامل
Relationship: نوع العلاقة
Phone no: رقم الهاتف
Email: البريد الالكتروني
Details of Feedback: تفاصيل الملاحظة
*
According to our Complaint Management Policy, we will investigate all complaints and will provide you feedback within seven days. While we aim to close all complaints within this timeframe, some may require a multidisciplinary review which may exceed seven days.
Submit
Section 1: (To be completed by the Quality Department)
Complaint Made By:
STAFF
PATIENT
FAMILY
VISITOR
NON-FAMILY
Other
Patient’s Name (if different from above):
If Patient; MRN :
Attach Patient Feedback:
Browse Files
Cancel
of
SAVE & UPDATE
Section 2: Initial follow-up
Name:
Date and Time
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Are/were you able to resolve the complaint:
Yes
No
Comments if any:
Document Reason:
Name:
Date and Time
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
SAVE & UPDATE
Section 3: Department Head to complete
Immediate ActionsTaken:
Preventative Measures:
Recommendations:
Follow-up required:
Policy review
Staff education
Other
Name:
Date and Time
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
SAVE & UPDATE
Section 4: Feedback to the Patient
Did you contact patient regarding resolution?
Yes
No
Date
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Did you offer Patient a meeting?
Yes
No
Meeting Date/Time
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
If “NO” did you discuss over the phone and was patient satisfied?
Yes
No
Comments:
SAVE & UPDATE
Section 5: Quality Use
Resolved
Not Resolved
Name:
Date and Time
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Reviewed by Director of Quality Dept.
Name:
Date and Time
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
SAVE & UPDATE
Should be Empty: