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?

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

Home Health Aide

Physical Therapist

Occupational Therapist

Speech Therapist

Social Worker

Dietician/Nutritionist

Please indicate any other staff from whom you received care:

Other

Please select the staff member(s) you received care from, and indicate their level of courtesy and respect:

Nurse

Home Health Aide

Physical Therapist

Occupational Therapist

Speech Therapist

Social Worker

Please indicate any other staff from whom you received care:

Other

How would you rate the overall care you received from our agency?

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)

Phone (Optional)