Thank you for staying at our hospital.

Your opinions and observations are important to us because our goal is to provide you with excellent quality of service and care throughout your stay. We would appreciate it if you could take a few minutes to complete the following questionnaire covering your hospital stay.

We will personally review each questionnaire and take action accordingly. We assure you that your comments remain confidential and if preferred your anonymity will be maintained.

This survey will take approximately 5 minutes to complete

 
Step 1 of 7
    * Your Details - These First Five Questions are Optional  
  Salutation (Mr, Mrs, Ms, Other) *  
  First Name : *  
  Last Name : *  
  Date of Admission : *  
  Email Address : *  
    Please Answer All Questions Below  
  Hospital Name :  
  About your Health Fund  
  Before entering hospital, did you contact your Health Fund for information or advice on Hospital fees and your likely ‘out of pocket’ costs?      YES    NO   
  Did you enquire or receive advice about medical costs from you Doctor?      YES    NO   
  If you had health cover, please indicate the fund name :  
  DVA:      YES    NO   
  Workers’ Compensation :      YES    NO   
  Self Insured :      YES    NO   


 

Step 2 of 7
  Admitting and Office Procedure Below Met Exceeded    
  Confirmation of booking prior to stay    
  Parking adequacy for you and your carers / friends    
  Information provided on your charges    
  Advice on out-of-pocket expenses    
  Courtesy and respect by office staff    
  Length of wait to be admitted to your room    
  Did you receive written or verbal information about the hospital prior to your admission?      YES    NO   
  Did you understand the privacy form that you signed?      YES    NO   
  Were you informed of your rights and responsibilities?               YES    NO   
  Would you return to our hospital for future care if required?      YES    NO   
    Yourself Your G.P Your Specialist Other    
  Who made the decision to stay at this hospital?    
    Local Advertising Advised by Doctor

Hospital Brochure

      
  How did you get to hear about our hospital?      


Step 3 of 7
  Hospital Facilities Below Met Exceeded      
  Locating the hospital      
  Orientation to your room and facilities      
  General presentation of the hospital      
  Décor of the room      
  Bathroom amenities      
  Telephone system      
  Cleanliness of the room      
  Temperature of the room      
  Acceptability of noise levels      
  Hydrotherapy Pool Facility (if applicable)      
  On admission, were you advised of the ‘Patient Information Directory’ which was located in your bedside locker?      YES    NO   


Step 4 of 7
  Clinical Care Below Met Exceeded      
  Provisions for privacy when needed      
  Pain management      
  Response to nurse call bell      
  Kept informed of your treatment and care      
  Relatives or carers kept informed      
  Courtesy and respect by nurses      
  Perceived competence of nurses      
  Attention of Doctor(s) to your condition      
  Courtesy and respect by Allied Health staff (physiotherapist, occupational therapist, social worker)      
  Physiotherapy clinical care if received      
  Diversional therapy group activities, if attended      
  Occupational therapy instruction, if received      
  Preparation for discharge      
  Theatre Services (if applicable)            
  Courtesy and respect by theatre staff      
  Nursing care received in the Operating Theatre      
  Notification of time change to operating schedule      
  Personal privacy valued      


Step 5 of 7
  Clinical Management    
  Were you involved in achieving a ‘daily goal’ in relation to your health and wellbeing?      YES    NO   
  Were you involved in the planning and decision making about your care whilst in hospital?      YES    NO   
  Did you receive and understand the information provided about your daily medications?      YES    NO   
  Who provided you with education and information about your daily medications?      Doctor    Nurse   
  If you wanted to make a formal complaint, compliment or comment did you know what to do?      YES    NO   
  Was adequate information provided, and arrangements made for your ongoing care following discharge?      YES    NO   
  Were you advised of what action to take if you had any concerns after you left the hospital?      YES    NO   


Step 6 of 7
  Catering Services Below Met Exceeded      
  Food and beverage quality      
  Hot food served hot      
  Cold food served cold      
  Presentation of the food served      
  Courtesy of the catering staff      
  Complimentary Care Below Met Exceeded      
  Aromatherapy treatments      
  Remedial therapy      
  Pastoral support      


Step 7 of 7
  Would you like a formal response to your comments?      YES    NO   
  Comments, if any:  
 

Thank you for your co-operation. We appreciate your taking the time to complete this questionnaire.
Press the 'submit' button below.