Healthcare: HCAHPS Hospital Survey
(Untitled)
1 of 1

Instructions:
 

  • You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.

  • Answer all the questions by checking the box to the left of your answer.

  • You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next.

  • Please answer the questions in this survey about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers.

YOUR CARE FROM NURSES

Q1. During this hospital stay, how often did nurses treat you with courtesy and respect?
Q2. During this hospital stay, how often did nurses listen carefully to you?
Q3. During this hospital stay, how often did nurses explain things in a way you could understand?
Q4. 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 DOCTORS

Q5. During this hospital stay, how often did doctors treat you with courtesy and respect?
Q6. During this hospital stay, how often did doctors listen carefully to you?

THE HOSPITAL ENVIRONMENT

Q7. During this hospital stay, how often did doctors explain things in a way you could understand?
Q8. During this hospital stay, how often were your room and bathroom kept clean?
Q9. During this hospital stay, how often was the area around your room quiet at night?

YOUR EXPERIENCES IN THIS HOSPITAL

Q10. During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?
Q11. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
Q12. During this hospital stay, did you need medicine for pain?
Q13. During this hospital stay, how often was your pain well controlled?
Q14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
Q15. During this hospital stay, were you given any medicine that you had not taken before?
Q16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?
Q17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

WHEN YOU LEFT THIS HOSPITAL

Q18. After you left the hospital, did you go directly to your own home, to someone else?s home, or to another health facility?
Q19. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?
Q20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

OVERALL RATING OF HOSPITAL

Please answer the following questions about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers.
Q21. 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 during your stay?
0 (Worst hospital possible)
1
2
3
4
5
6
7
8
9
10 (Best hospital possible)
Ranking:
Q22. Would you recommend this hospital to your friends and family?

UNDERSTANDING YOUR CARE WHEN YOU LEFT THE HOSPITAL

Q23. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
Q24. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
Q25. When I left the hospital, I clearly understood the purpose for taking each of my medications.

ABOUT YOU

Q26. During this hospital stay, were you admitted to this hospital through the Emergency Room?
Q27. In general, how would you rate your overall health?
Q28. In general, how would you rate your overall mental or emotional health?
Q29. What is the highest grade or level of school that you have completed?
Q30. Are you of Spanish, Hispanic or Latino origin or descent?
Q31. What is your race? Please choose one or more.
Q32. What language do you mainly speak at home?
1 of 1