Secure Patient Satisfaction Questionaire

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Date of Admission
Last Name: (Optional)
First Name: (Optional)
Phone:
Address
Address 2
City State Zip Code
Email

Dear Patient,

Below are a number of questions about your most recent visit to Stonewall Jackson Memorial Hospital. We are constantly seeking to improve our service to you and the community. We ask that you take a few minutes to complete this survey. Your comments are confidential. We welcome any suggestions or comments that you have concerning the quality of care you received.

  Excellent Good Average
Poor
 Very Poor Doesn't Apply
1. In general, how do you rate our hospital?
2. How was our Registration Department?
3. If you were admitted through the ER, how was the ER Dept.?
4. How were nursing services?
5. How was Respiratory care staff? (courteous and knowledgable?)
6. How was Radiology staff? (courteous and knowledgable?)
7. How was Laboratory staff? (courteous and knowledgable?)
8. How was Physical Therapy staff? (courteous and knowledgable)
9. How was Dietary Staff? (food good?)
10. How was Housekeeping (were things clean?)
11. How was Maintenance (were things in working order?)
12. How was your attending physician?
13. How do you rate your communication with him/her?
14. How was Social Service and Discharge planning?
15. Were your take-home instructions clear and concise?
16. How was your room and accommodations?
17. Rate our treatment of your visitors.
18. Were you offered education for your condition? (circle one) Yes No Doesn't Apply
19. Were you offered education on quitting tobacco products? (circle one) Yes No Doesn't Apply
20. Did you need and receive pain medication? (circle one) Yes No Doesn't Apply
21. Was your pain relieved adequately? (circle one) Yes No Doesn't Apply
22. Would you recommend this hospital to a family member? (circle one) Yes No Doesn't Apply

Do you have any comments regarding the safety of your hospital experience?

Do you have any other comments about your hospital experience?

Thank you very much for taking the time to help us improve. You may now click the submit button below to send your information If you wish to speak to someone regarding your care, please call Director of Accreditation at 304.269.8501