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TELL US WHAT YOU THINK
In our continuing effort to provide the bet
possible health care, we are asking patients to evaluate the
treatment and service they receive in our Surgery Center.
Your opinion makes all the difference to
us. We care what you think. If you would take a few
minutes to fill out the questionnaire below, it would be very much
appreciated. Please check the boxes and/or add additional
comments if desired.
By telling us how you feel you will give us the
opportunity to better respond to your needs - or those of your
relatives and friends - in the future. Thanks for your
help. Again, your opinion is important to us.
Or you can download our IN OFFICE SURVEY and send it to us!
Date of Procedure
Name of Surgeon
Procedure
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| 1. |
Length
Of Wait |
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A. Do you feel
that the length of time you had to wait for your procedure to
begin was appropriate? The waiting time was.....
Shorter
than I expected
A reasonable length of time
Too long
If unacceptable, why?
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| 2. |
Facilities
/ Environment |
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A. Was the
facility clean and comfortable?
Yes
No |
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B. Was your privacy
provided for and respected?
Yes
No
If unacceptable, why?
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| 3. |
Courtesy
And Attitude Of Staff |
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Was our staff
courteous and polite? Did they go beyond this and show an
attentive, caring attitude?
Excellent
Acceptable
Unacceptable |
| Receptionist |
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| Nurses |
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| Doctor |
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| Anesthesia Staff |
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| Billing Staff |
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If
unacceptable, why?
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| 4. |
Ability
To Communicate |
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A. Did the
doctor and nursing staff clearly explain your treatment to you,
give clear information and answer your questions?
Excellent
Acceptable
Unacceptable |
| Nurses |
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| Doctor |
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| Anesthesia Staff |
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If unacceptable,
why?
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B. Were your
discharge instructions clear? Did you know what to do when
you went home?
Yes
To some
extent
No
If unacceptable, why?
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| 5. |
Quality
Of Care |
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A. Please rate
the quality of care you feel you received from our staff?
Was it merely adequate? Or did the staff seem highly
competent and inspire your confidence?
Excellent
Acceptable
Unacceptable |
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Nurses |
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Doctor |
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Anesthesia Staff |
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B. If you had
another procedure, would you return to the Creve Coeur Surgery
Center?
Yes
No
Maybe
If unacceptable, why?
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| 6. |
Registration
/ Billing |
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A. Did you find
the registration process smooth and to your satisfaction?
Yes
No |
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B. Were the
forms you signed explained to you?
Yes
No |
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C. Was
financial responsibility for your procedure made clear?
Yes
No
If unacceptable, why?
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| 8. |
What could we
have done differently to make your stay better or improve our
Surgery Center? |
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Name: (Optional)
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