• E-mail
• Print
• RSS

Free form: Satisfaction survey for PCPs

Hospitalist Leadership Connection, January 11, 2011

Your satisfaction with the hospitalist services provided at [name of hospital] is important to us. To help us better serve you in the future, please check the box that best describes how you feel about our services.

PATIENT INFORMATION (to be completed by [name of hospital] hospitalist or designated staff member)

Patient name:
Admission date:
Primary care provider:
Discharge date:

1.    Admitted from:
[  ] Primary care provider (PCP)’s office
[  ] Emergency department
[  ] Direct from home
[  ] Nursing facility
[  ] Other

2.    Admitted to:
[  ] [name of hospital]
[  ] [name of alternate facility, if applicable]

INFORMATION FLOW (to be completed by patient’s PCP)

3.    I was informed of the patient’s admission to [name of hospital].
[  ] Yes
[  ] No

4.    I received a copy of the patient’s history and physician examination.
[  ] Yes
[  ] No

5.    I received the patient’s discharge summary in a timely manner.
[  ] Yes
[  ] No

6.    I was informed of the patient’s progress on a regular basis.
[  ] Yes
[  ] No

COMMUNICATION (to be completed by patient’s PCP)

7.    Grade the [name of hospitalist program] hospitalists in terms of how well they involved you in your patient’s treatment plan:
[  ] Excellent
[  ] Very good
[  ] Good
[  ] Fair
[  ] Poor

8.    Did you agree with the treatment plan?
[  ] Yes
[  ] No
If not, please explain.

9.    Was the discharge plan appropriate?
[  ] Yes
[  ] No
If not, please explain.

10.    Was the discharge summary complete?
[  ] Yes
[  ] No
If not, please explain.

11.    My patient’s opinion of the overall care he or she received at [name of hospital] was:
[  ] Excellent
[  ] Very good
[  ] Good
[  ] Fair
[  ] Poor

12.    My overall satisfaction with the hospitalist services at [name of hospital] is:
[  ] Excellent
[  ] Very good
[  ] Good
[  ] Fair
[  ] Poor

The above except is adapted from Hospitalist Case Studies: Tactics and Strategies for 10 Common Hurdles, published by HCPro, Inc.

• E-mail to a Colleague
• Print
• RSS
• Archive