Patients Experience Survey
I. DATA PRIVACY CONTENT
INFORMATION REGISTRATION & GENERAL CONSENT
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IMPORTANT: PLEASE READ CAREFULLY. YOU MAY REQUEST THE HOSPITAL STAFF TO EXPLAIN TO YOU, OR TO REFER YOU TO SOMEONE WHO CAN EXPLAIN TO YOU, YOUR RIGHTS TO YOUR PERSONAL INFORMATION. In the course of your treatment, Sacred Heart Hospital of Malolos, Inc. (the “Hospital”) will process Personal Information and Sensitive Personal relating to you and/or your spouse/parents/children/relatives/guardian/companion (“Contacts”), as applicable. Such processing of Personal Information may include its collection, recording, updating, modification, retrieval, use and retention. These Personal Information include information which may use for identification purposes and other personal circumstances such as your name, age, date of birth, address, nationality, gender, religious affiliation, contact information, educational background, medical information, medication, medical history and other information which are relevant for the purpose of your diagnosis and treatment in the Hospital. In signing this consent form, you are giving your consent to the following: 1) The processing of your Personal Information, as provided under applicable laws, regulations and the Hospital’s policies and guidelines, for its and its affiliates’ related entities and partners’ legitimate purpose/s including your testing, diagnosis, and treatment. 2) Making your Personal Information available to the Hospital, its affiliates, related entities, and partners (including its service providers as well as members of its medical staff and doctors) (Hospital related Entities), and to permit the Hospital Related Entities to make your personal data available to (a) third parties who provide products and services to the Hospital and the Related Hospital Entities for the same purpose described above; and (b) to other third parties (such as, but not limited to, the Department of Health, Philippine Health Insurance Corporation, your employer or your insurance provider), where required or permitted by law or contract, including regulatory authorities, government agencies, as well as parties with whom you voluntarily transact. 3) The processing of your Personal Information for medical training, research, and education, as well as to generate statistical data relevant to the Hospital’s operation in order to aid the Hospital’s management team, board of directors and shareholders to review and analyze data relating to the Hospital’s operations and financial performance. You also warrant that, before providing us with the Personal Information of your Contacts, you have obtained their consent to: (a) you collecting their Personal Information; (b) you sharing the same with the Hospital and the Hospital Related Entities and their third parties that the Hospital Related Entities are dealing with as provided in the immediately preceding paragraph; and (c) to the processing of their Personal Information by the Hospital, the Hospital related Entities and third parties as provided herein, and for the purposes stated herein. The Personal Information you provide will be retained by the Hospital for a period of 15 years (“Personal data retention Period”), or as long as necessary for the purpose of maintaining your medical records and to comply with applicable laws, rules and regulations on retention of data. Unless retention for longer period is required for reasonable cause, we will dispose of your Personal Information upon the lapse of the Personal Data Retention Period in accordance with applicable laws and regulations. You and your Contacts are entitled to certain rights in relation to the Personal Information that may be collected from you and your Contacts, including the right to access, correction, and to object to the processing of the same. A more detailed description of your rights under the Philippine Data Privacy Act of 2012, and its implementing rules and regulations may be downloaded at https://privacy.gov.ph/implementing-rules-and-regulations-of-republic-act-no-10173-known-as-the-data-privacy-act-of-2012/ You may consult the Hospital’s Data Protection Officer or the National Privacy Commission (contact details provided below) for any concerns regarding your Personal Data. Hospital’s Data Protection Officer Riavelle Love D. Santos (044) 794-4744; 794-7135 Diagnostic and Medical Arts Bldg., Sacred Heart Hospital of Malolos, Bulacan 3000 National Privacy Commission (0945) 153-4299 / (0939) 8715 3rd Floor, Core G, GSIS Headquarters Bldg. Financial Center, Pasay City, Metro Manila 1308
II. Tell us about yourself
Patient Type
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Outpatient (hindi naconfine)
Inpatient (naconfine)
Room No.
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Date of confinement
*
-
Month
-
Day
Year
Date
Date of Visit
*
-
Month
-
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
With Companion
*
Yes
No
Name of Companion
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Address
*
Street/Barangay
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
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How did you find out about Sacred Heart Hospital of Malolos?
*
Recommendation of Friends/Family
Social Media Platform (Facebook, etc.)
Health Plan/ Insurance (HMO)
Doctor's Referral
Traditional Media (Posters, Billboards, Radio/TV ads)
Other
Was this your first visit to Sacred heart Hospital of Malolos?
*
Yes
No
Our Doctors
Poor
Fair
Good
Very Good
Excellent
Courtesy and Respect of Staff
Clarity of Instruction
Quality of Care
Promptness
Hospital Environment and Facility
Poor
Fair
Good
Very Good
Excellent
Cleanliness
Comfort During Your Stay
Quality of Linen
Toilet and Bathroom (sink, faucet, toilet, flush)
Room Amenities (bed, cabinet, ref, etc.)
Dietary Services
Poor
Fair
Good
Very Good
Excellent
On Time Delivery
Appropriate Food for the Diet of the patient
Courtesy and Respect of Staff
Taste of Meals
On Time Collection
Presentation of Meals
Care for our Nurses
Poor
Fair
Good
Very Good
Excellent
Promptness
Courtesy and respect of staff
Clarify of Instruction
Timeless of Medication
Quality of Care
Our Discharge Process: Billing/Cashier
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Promptness
Our Process
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Promptness
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Ancillary and Other Department
Please leave a rating for each department visited
Which services would you like to rate?
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Admitting
Audiometry
Ambulance
Cashier
Credit and Collection
Doctor's Clinics
Dietary Counseling
Emergency Room (ER)
Hemodialysis Unit (HD)
Heart Station
HMO/Billing
Housekeeping Services
Information
Laboratory
Neurosciences
OB Ultrasound
Operating Room (OR)
Oncology Unit
Pharmacy
Parking Services
Rehab Unit
Radiology
Respiratory Therapy
Security
Wound care
Emergency Room (ER)
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Quality of Care
Promptness
Efficiency
Timeliness
Ambulance
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Quality of Care
Equipment
Efficiency
Timeliness
Woundcare
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Quality of Care
Promptness
Efficiency
Timeliness
Oncology Unit
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Quality of Care
Promptness
Efficiency
Timeliness
Dietary counseling
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Quality of Care
Promptness
Efficiency
Timeliness
Hemodialysis Unit (HD)
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Quality of Care
Promptness
Efficiency
Timeliness
Pharmacy
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Cashier
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
HMO/Billing
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Credit and Collection
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Respiratory Therapy
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Heart Station
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Quality of Care
Rehab Unit
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Quality of Care
Information
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Admitting
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Operating Room
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Quality of Care
Neurosciences
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Quality of Care
Laboratory
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Release of Results
Proficiency of Staff
Radiology
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Release of Results
Proficiency of Staff
Security
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Housekeeping Services
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Doctor's Clinics
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Quality of Care
OB Ultrasound
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Quality of Care
Audiometry
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Timeliness
Quality of Care
Parking Service
*
Poor
Fair
Good
Very Good
Excellent
Courtesy and respect of staff
Availability
Cleanliness
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Comment and Suggestion
Suggestion and Recommendation
Was there any staff member who provide excellent care or service during stay?
*
Yes
No
Who?
*
if there are multiple staff members you want to commend, You can write all their names separated by a coma.
How was your overall experience with us?
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Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Will you recommend Sacred Heart Hospital of Malolos to others?
*
Yes
No
Why?
*
How likely are you to recommend Sacred Heart Hospital of Malolos to your friends and family?
*
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
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