CMS Information Transfer Survey
This is a brief survey that should take you about 5 minutes. You are recieving this survey because you recently had a procedure at Glen Rose Medical Center. Either before or after your procedure, you should have been given information about what to do during your recovery process. For example, you may have received a packet of information, video, or had a conversation or phone call that instructed you on what to do after your procedure. We would like to know if this information was easy to follow. Your survey responses will help your doctors and hospital improve the quality of care they provide. Your responses are completely anonymous, neither your name nor any other identifying infomration will be shared with your doctor or hospital. This survey can be filled out by you or your caregiver.
Eligibility Determination
Are you over the age of 18?
Yes
No
Did you have a procedure or surgery at Glen Rose Medical Center recently (within the last 65 calendar days)?
Yes
No
Section 1: Information Took Into Account My Needs
1. Your health needs (for example: medical conditions, pain management, treatment preferences, etc.)
Yes
Somewhat
No
2. Your personal situation (for example: transportation needs, insurance coverage, financial status, etc.)
Yes
Somewhat
No
Section 2: Medications
3. Why you should take any new medications
Very clear
Somewhat clear
Not clear
Does not apply
4. Possible side effects of new medications
Very clear
Somewhat clear
Not clear
Does not apply
5. When to stop any medications
Very clear
Somewhat clear
Not clear
Does not apply
Section 3: Daily Activities
6. Changes to your diet
Very clear
Somewhat clear
Not clear
Does not apply
7. Changes to physical activities, including exercise.
Very clear
Somewhat clear
Not clear
Does not apply
8. When you could return to work
Very clear
Somewhat clear
Not clear
Does not apply
9. When you could drive
Very clear
Somewhat clear
Not clear
Does not apply
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