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ED Patient Experience Survey
Your feedback helps us improve emergency care. Please answer the following questions about your recent visit. All questions are optional.
About your visit
Visit date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who is filling this out?
Patient
Family / friend
Age group
18–44
45–64
65+
Needed help reading this?
No
Yes
Your experience in the Emergency Department
Did the staff treat you with courtesy and respect?
Always
Usually
Sometimes
Never
Did nurses and doctors explain things in a way you could understand?
Always
Usually
Sometimes
Never
If you had to wait, did someone tell you why you were waiting?
Yes
No
I did not have to wait
Did you get help with pain or other symptoms when you needed it?
Yes
No
I did not need help
Was the staff competent in the care they delivered?
Yes
No
Before you left, did someone explain what to do at home and what warning signs to watch for?
Yes
No
Not sure / does not apply
Did you understand your medicines?
Yes
No
Not sure / does not apply
Did you know who to call if you had a problem after you left?
Yes
No
Not sure / does not apply
Overall ratings
Overall, how would you rate the care you received?
Excellent
Very good
Good
Fair
Poor
Would you recommend this hospital to your family or friends?
Definitely yes
Probably yes
Probably no
Definitely no
Open feedback
What is one thing we could do better?
Staff-only tracking section
Survey offered at ED discharge / Envelope given / Patient declined / Phone survey completed on follow-up call
Survey offered at ED discharge
Envelope given
Patient declined
Phone survey completed on follow-up call
Date offered
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff initials
Optional encounter # / MRN (QA only)
Return path
Drop box
Mail
QR / web
Phone
Received by QA
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Survey
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