Patient Satisfaction Questionnaire

Excellent

Fair

Poor

1. Please rate the quality of information you received from the Surgery Center regarding preoperative information.

5

4

3

2

1

0

2. Please rate the quality of information and education you received from:

Reception and Registration

5

4

3

2

1

0

Business Office / Insurance Verification

5

4

3

2

1

0

Admitting Nurse

5

4

3

2

1

0

Operating Room / Procedure Room Staff

5

4

3

2

1

0

Anesthesiologist / Sedation nurse

5

4

3

2

1

0

Surgeon / Endoscopist / Pain Physician

5

4

3

2

1

0

Recovery Room Staff

5

4

3

2

1

0

Discharge Prevention Pamphlet

5

4

3

2

1

0

3. Please rate the quality of care (medical/ nursing) you received from:

Admitting Nurse

5

4

3

2

1

0

Operating Room / Procedure Room Staff

5

4

3

2

1

0

Anesthesiologist / Sedation nurse

5

4

3

2

1

0

Surgeon / Endoscopist / Pain Physician

5

4

3

2

1

0

Recovery Room Staff

5

4

3

2

1

0

4. Overall, how well did the staff protect your dignity and privacy, and ensure your comfort?

5

4

3

2

1

0

5. Please rate the cleanliness and appearance of the Surgery Center.

5

4

3

2

1

0

6. What did you like best about your experience at the Surgery Center?

7. What did you like least about your experience at the Surgery Center?

8. Were any Surgery/procedure delays adequately explained?

Yes

No

9. Do you have any additional comments or suggestions? We encourage you to share your thoughts on how we might improve our services, or if there is someone's care that stood out who you would like to recognize - we would appreciate hearing from you. (Thank you for your additional comments.)

10. Overall, I was satisfied with my care and I would recommend Bend Surgery Center to a family member.

5

4

3

2

1

0

Signature (optional)Type of procedure Date

Patient Satisfaction Questionnarie