Patient Survey Date* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM Patient Name:* Patient Date of Birth:* MM slash DD slash YYYY Name of Person Completing the Survey: The following questions are in regards to a Nurse or Admin?*I'd rather not sayNurseAdminDo you feel the needs / wants of the patient are being met & are being provided, in accordance with the Plan of Care?* Yes No I do not know Do you feel the patient is being cared for in a comfortable & non discriminatory way?* Yes No Are you notified in advance if your Nurse is going to be changed?* Yes No Are you notified in advance if your regular services have to be rescheduled?* Yes No Were you advised who would be supervising your Nurse?* Yes No Were you advised who you may contact should you wish to speak to someone other than your Nurse?* Yes No Does your Nurse show up for work on time?* Yes No Is there anything that concerns you about your Nurse?* Yes, please explain in comments section No Are you asked to sign the visit note documenting the Nurse's time in and time out?* Yes No Does your Nurse stay for the specified time?* Yes No Did our staff explain the patient's rights to you?* Yes No Is there anything you don't like about our service?* Yes, please explain in comments section No Do you have any suggestions for ways we can improve our service?* Yes, please explain in comments section No Do you feel we have the required knowledge & skills to deliver quality services?* Yes No How would you rate the overall quality of service you received?* Excellent Good Fair Poor How would you rate the Nurse caring for your child?* Excellent Good Fair Poor Would you refer a friend or relative to Little Miracles Home Health for services?* Yes No Comments*CAPTCHANameThis field is for validation purposes and should be left unchanged.
