* = Required Information
Patient Name:
*
Date of Service:
*
In an effort to provide the highest quality of care and service to our patients, Elder's Choice, Inc. would like to know your opinion of the care you or your family member received from us. Your input is very valuable. It helps us determine what we are doing right and where we need to make changes to improve our program. Please share your thoughts about our services and our staff.
Services Received:
Skilled Nursing
Home Health Aide
Social Worker
Occupational Therapy
Physical Therapy
Speech Therapist
1. Were you informed of the names of Agency personnel providing your care?
Yes
No
Explain
2. Were you kept informed of your scheduled visits and any changes in schedule?
Yes
No
Explain
3. Were visits made as scheduled?
Yes
No
Explain
4. Were there frequent changes in Agency Personnel?
Yes
No
Explain
5. At each visits, did you feel as though you received enough time and attention?
Yes
No
Explain
6. Did you receive instructions that you could clearly understand and find useful in assisting you to manage your illness/disease?
Yes
No
Explain
7. Upon discharge, were you given clear, understandable instructions regarding follow-up care?
Yes
No
Explain
8. Do you know how to report complaints/abuse about home care?
Yes
No
Explain
9. Was the Staff polite, courteous, well groomed, and appropriately dressed?
Yes
No
Explain
10. Would you use our services again if needed?
Yes
No
Explain
Would you like someone to contact you about this survey?
Yes
No
If Yes, please leave your contact information so we can get back to you:
Name:
Relation to patient:
Phone:
Best time to call:
AM
PM
Security Code
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