Patient Satisfaction Survey

Please take a minute to provide your feedback about the care and services we provided.
Over what period of time did you receive home health services from our agency?
From Date
To Date
What services did you receive from our agency?
- Skilled Nursing Services
- Home Health Aide
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Alzheimers/Dementia Care
- Catheter Care
- Wound Care
- Pain Management
- Other

If Other, please add any other services you received:

Did your nurse, therapist or aide introduced him/herself and explain the plan of care, allowing me and/or my caregiver to ask questions?
- Yes
- No
- Not Sure
Was the patient and/or the family involved in the decision making regarding the plan of care?
- Yes
- No
- Not Sure
Were you informed how to contact the home health staff after hours, on weekends and holidays?
- Yes
- No
- Not Sure
Did our staff explain your rights and responsibilities as a patient/family member?
- Yes
- No
- Not Sure
Did our staff give instructions and information in terms you could understand?
- Yes
- No
- Not Sure
Please select the staff member(s) you received care from, and rate the care you received from each:
Nurse
- Excellent
- Good
- Fair
- Poor
- N/A
Home Health Aide
- Excellent
- Good
- Fair
- Poor
- N/A
Physical Therapist
- Excellent
- Good
- Fair
- Poor
- N/A
Occupational Therapist
- Excellent
- Good
- Fair
- Poor
- N/A
Speech Therapist
- Excellent
- Good
- Fair
- Poor
- N/A
Social Worker
- Excellent
- Good
- Fair
- Poor
- N/A
Dietician/Nutritionist
- Excellent
- Good
- Fair
- Poor
- N/A
Please indicate any other staff from whom you received care:
Other
- Excellent
- Good
- Fair
- Poor
- N/A
Please select the staff member(s) you received care from, and indicate their level of courtesy and respect:
Nurse
- Excellent
- Good
- Fair
- Poor
- N/A
Home Health Aide
- Excellent
- Good
- Fair
- Poor
- N/A
Physical Therapist
- Excellent
- Good
- Fair
- Poor
- N/A
Occupational Therapist
- Excellent
- Good
- Fair
- Poor
- N/A
Speech Therapist
- Excellent
- Good
- Fair
- Poor
- N/A
Social Worker
- Excellent
- Good
- Fair
- Poor
- N/A
Please indicate any other staff from whom you received care:
Other
- Excellent
- Good
- Fair
- Poor
- N/A
How would you rate the overall care you received from our agency?
- Excellent
- Good
- Fair
- Poor
- N/A
If a friend or family member needed home health care in the future, would you recommend our agency?
- Yes
- No
- Not Sure
If no, or you are not sure, please let us know what we can do improve?
We welcome any additional comments, and appreciate any recognition of members of our team.
Name (Optional)
First Last
Email (Optional)
Thank you for taking the time to give us your feedback.