Patient and Visitor Feedback What facility would you like to give feedback?*Choose facilityDopson Family Medical CenterEd Fraser Memorial HospitalEmergency DepartmentBaker Rural Health ClinicHospital CAHPSW. Frank Wells Nursing HomePhysical TherapyGeneral InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Our state agency is also available to discuss concerns with. They may be reached by calling the Consumer Assistance Unit at 1.888.419.3456, or by writing to: Agency for Health Care Administration, Consumer Assistance Unit, 2727 Mahan Dr./Building 1, Tallahassee, FL 32308Physical Therapy: Patient Satisfaction SurveyHelp us to improve service to our patients. Please take a few minutes to fill out this questionnaire regarding your experience with our physical therapy department. Thank you for your input.After arriving at the rehabilitation department, how long, on average did you have to wait for your treatment?*5 minutes15 minutes30 minutesMore than 30 minutesWas the staff professional and courteous?*YesNoIf you had to wait, were you given an explanation by the staff?*YesNoDid you find the physical therapy treatments helpful?*YesNoPlease describe what kind of treatment you received:*Did you feel like you had enough privacy during your treatments?*YesNoDid you feel that our staff spent enough time with you while you were receiving your threrapy?*YesNoDid you keep your scheduled appointment with us?*YesNoDo you have any suggestions or comments that may help us to improve our services to you and our other patients?*W. Frank Wells Nursing Home: Patient Satisfaction SurveyWe take all of your concerns and complaints seriously and strive to continually improve the quality of care in our facility. Please take a moment and drop us a line about any concern you may have. We want to provide excellent care for you here at W. Frank Wells Nursing Home. Please let us know if you have a compliment or suggestion, or have had a problem with any part of your care here. Your input is important to us. You may contact us through our Risk Manager by phone at 904.259.6168, or in writing by completing this form and submitting it directly to that department. All grievances will be reviewed by the Risk Manager, and you will receive a written response. If you would like us to respond, be sure to complete all of the information below.What was your general impression of the nursing home?ExcellentGoodAveragePoorAdmitting OfficeExcellentGoodAveragePoorCourtesyPromptnessIntroduction to nursing home policies and routinesAccommodationsExcellentGoodAveragePoorComfortCleanlinessLightingVentilationQuietnessNursing StaffExcellentGoodAveragePoorEfficiencyPromptnessCheerfulnessConcernTreatment by other nursing home personnelExcellentGoodAveragePoorLaboratory techniciansX-ray techniciansDietary personnelEmergency Room personnelRespiratory therapy personnelHousekeeping personnelPhysical therapy personnelOperating room personnelYour daily scheduleExcellentGoodAveragePoorActivityRestFoodExcellentGoodAveragePoorAppetizingAttractiveSufficientServiceWas hot food hot?Was cold food cold?Were you on a special diet? Yes No Treatment of your visitorsExcellentGoodAveragePoorAt the information deskBy the nursing staffGeneral visiting hours and regulationsServicesExcellentGoodAveragePoorTelephoneMail deliveryFlower delivery and careBusiness office arrangementsExcellentGoodAveragePoorCourtesyPromptnessAdequate explanationCommentsSuggestions for improvementsWhat was your room number?200A200B201A201B202A202B203A203B204A204B205A205B206A206B207A207B208A208B209210A210B211212A212B213A213B214A214B215A215B216A216B217A217B218A218B219A219B220221A221B222223A223B224A224B225A225B226A226B227A227B228A228B229A229B230A230B231A231B232A232B233A233B234A234B235A235BWas this you first visit? Yes No Date of discharge MM slash DD slash YYYY Ed Fraser: Patient Satisfaction SurveyWe want to provide excellent care for you in our facilities. Please let us know if you have a compliment or suggestion, or have had a problem with any part of your care here. We take all of your concerns and compliments seriously and strive to continually improve the quality of care in our facilities. Your input is important to us. You may contact us through our Quality Management Director by phone at 904.259.3151. All grievances will be reviewed and you will receive a written response. If you would like us to respond, please be sure to complete all of the information below. You may also pick up a hard copy of this form at either of our facilities.Date of visit MM slash DD slash YYYY Department visitedComment or concernDopson Family Medical Center: Patient Satisfaction SurveyWe want to provide excellent care for you in our facilities. Please let us know if you have a compliment or suggestion, or have had a problem with any part of your care here. We take all of your concerns and compliments seriously and strive to continually improve the quality of care in our facilities. Your input is important to us. All grievances will be reviewed and you will receive a written response. If you would like us to respond, please be sure to complete all of the information below. You may also pick up a hard copy of this form at either of our facilities.Date of visit MM slash DD slash YYYY Department visitedComment or concernHospital CAHPS: Patient Satisfaction SurveyYou should only fill out this survey if you were the patient during the hospital stay. Do not fill out this survey if you were not the patient. Answer all the questions by selecting one of the circles to the left of your answer. All information that would let someone identify you or your family will be kept private. Please answer the questions in this survey about your stay at Ed Fraser Memorial Hospital. Do not include any other hospital stay in your answers.Your Care from NursesNeverSometimesUsuallyAlwaysDuring this hospital stay, how often did nurses treat you with courtesy and respect?During this hospital stay, how often did nurses listen carefully to you?During this hospital stay, how often did nurses explain things in a way you could understand?During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?Your Care from DoctorsNeverSometimesUsuallyAlwaysDuring this hospital stay, how often did doctors treat you with courtesy and respect?During this hospital stay, how often did doctors listen carefully to you?During this hospital stay, how often did doctors explain things in a way you could understand?The Hospital EnvironmentNeverSometimesUsuallyAlwaysDuring this hospital stay, how often were your room and bathroom kept clean?During this hospital stay, how often was the area around your room quiet at night?Your Experiences in this HospitalYesNoDuring this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?During this hospital stay, did you need medicine for pain?During this hospital stay, were you given any medicine that you had not taken before?When You Left the HospitalOwn homeSomeone else's homeAnother health facilityAfter you left the hospital, did you go directly to your own home, to someone else’s home, or to another health facility?Overall Rating of Hospital1 - Worst hospital possible2345678910 - Best hospital possiblePlease answer the following questions about your stay at Ed Fraser Memorial Hospital. Do not include any other hospital stays in your answer. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital?Would you recommend this hospital to your friends and family? Definitely no Probably no Probably yes Definitely yes In general, how would you rate your overall health? Excellent Very Good Good Average Poor In general, how would you rate your overall health? Excellent Very Good Good Average Poor What is the highest grade or level of school that you have completed?8th grade or lessSome high school, but did not graduateHigh school graduate or GEDSome college or 2-year degree4-year college graduateMore than 4-year college degreeAre you of Hispanic or Latino origin or descent?Yes, Hispanic or LatinoNo, not Hispanic or LatinoWhat is your race? Please choose one or more. White Black or African American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native What language do you mainly speak at home? English Spanish Baker Rural Health Clinic: Patient Satisfaction Survey We want to provide excellent care for you in our facilities. Please let us know if you have a compliment or suggestion, or have had a problem with any part of your care here. We take all of your concerns and compliments seriously and strive to continually improve the quality of care in our facilities. Your input is important to us. All grievances will be reviewed and you will receive a written response. If you would like us to respond, please be sure to complete all of the information below. You may also pick up a hard copy of this form at either of our facilities.Date of visit MM slash DD slash YYYY Department visitedComment or concernEmergency Department: Patient Satisfaction Survey Help us to improve service to our patients. Please take a few minutes to fill out this questionnaire regarding your experience with our emergency department. Thank you for your input.Date of visit MM slash DD slash YYYY Time of visit : Hours Minutes AM PM AM/PM Were our admitting personnel courteous, understanding and efficient?YesNoN/AGiven the volume of patients waiting for treatment at the time of your visit, do you feel the time spent waiting to be seen was appropriate?YesNoN/AAbout how long did you wait (in minutes)?If you experienced a delay, at what point in your care did it occur? Waiting for initial exam (triage) Waiting to be registered (signed in) Waiting to be taken to ED bed Waiting to be seen by a physician Waiting for lab tests Waiting for radiology tests Waiting for treatment (meds, dressings, etc.) Waiting for discharge Physician/Staff:YesNoN/AIf you were required to wait, was an explanation given to you by the staff?If you were required to wait, was an explanation given to you by the staff?Did the physician/staff explain your treatment and any follow-up care that may have been necessary?Did the physician/staff answer any questions you may have had?Was the facility clean and well maintained at the time of your visit?If you were seen by personnel in the following departments, were they courteous and understanding?YesNoN/ALaboratoryRadiology (x-ray)Physical TherapyRespiratory Therapy (EKG)Were you satisfied with the care you received in our Emergency Department?YesNoN/ADo you have any suggestions that would help us improve our services?Would you like to talk with a hospital representative?YesNo
