FEEDBACK FORM
Dear Sir / Mam,
Vaatsalya Group of Hospitals strives to deliver Care with and to follow ‘Ethical Practice’. We
appreciate the time taken to complete this form and truly value your suggestions that we hope will enable us to provide the highest quality patient care. Name : ....................................................
MRN No: ...............................
Contact Number : .....................................
Email ID: ................................
Treating Doctor: ........................................
Date : ....................................
Is this your first time visit to this Hospital?
Yes
No
Why did you choose the Hospital: ........................................................................ Doctor’s Recommendation : ......................
Insurance Requirement : ..................
Friends or Relatives Recommendation : ......................
Location : .......................................
Reputation of the Hospital
Others : .........................................
Excellent
Good
Average
Should Improve
No comments
1. REGISTRATION - How would you rate each of the following ? i. External Access to the Hospital ? ii. Telephone Information ? iii. Greeting on Arrival ? iv. Promptness of appointment ? v. How would you rate the behaviour of the Reception staff ? 2. DOCTOR i. How clear was the doctors explanation on the ailment & reason for admission? ii. How would you rate the Doctor ? iii. Regular visits by the Doctor ? 3. ADMISSION PROCESS – i. How was the explanation on ward charges and surgery charges ? ii. How was the explanation on billing estimate given to you ? iii. Waiting time for Admission ? 10 min 15 min 20 min 30 min < 30 min 4. INSURANCE – to be filled by Insurance card holders (Govt. & Non-Govt.) i. How clear was the staff’s explanation on the insurance process? 5. How would you rate each of the following ? i. Directions given by the staff ? ii. Internal Signages could guide you to the departments ? iii. How would the rate the Emergency Department ?
6. CLEANLINESS i. How would you rate the cleanliness of your room/ward ? ii. How would you rate the bed sheets provided ? iii. How would you rate the behaviour of the Housekeeping staff ? iv. How would you rate the cleanliness of the hospital ? 7. NURSING i. How would you rate the response of the Nurses during the day time ? ii. How would you rate the response of the Nurses during night hours ? iii. How would rate the care given by the Nurses ? iv. How would you rate the behaviour of the Nurses ? 8. DISCHARGE PROCESS 30 min 45 min 1 hour 1.5 hour more then 1.5 i. Time taken for Discharge ? ii. How would you rate the explanation of bill by the staff ? iii. Was the discharge Summary provided ? 9. PHARMACY i. Availability for prescribed Medicine ? ii. Waiting time for the Medicine ? iii. How would you rate the behaviour of the staff ? 10. LABORATORY i. How would you rate the Laboratory (sample collection area) ii. How would you rate the Laboratory Reporting Time iii. How would you rate the behaviour of the Lab. Staff 11. OTHER SERVICES i. How were the parking services ? ii. How good are the Security Services ? 12. On a scale of 0 - 10, How likely are you to recommend Vaatsalya Hospital to a friend or relative ? 1 13.
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Area of Work ...........................................
Reason .................................................................................................................................... Please feel free to use this space to add any comments or suggestions:
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