Patient Outcome Survey (mailed version)

Re-Engineered Discharge (RED) Toolkit

This survey available for download in two formats:

For hospitals needing translation services, a helpful reference to a national translation service is available at: http://www.atanet.org/onlinedirectories/ .


HOSPITAL DISCHARGE SURVEY

SURVEY INSTRUCTIONS

  • You should fill out this survey only if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.
  • Answer all the questions by checking the box next to your response.
HOSPITAL USE

1.   Have you stayed in a hospital overnight since you left the hospital on {discharge date}? This means being admitted to a hospital floor (not just the emergency room).

1___ Yes   2___ No

If YES, please fill out the table below for each hospital visit. List the hospital, date of arrival, and reason for each hospitalization.

HospitalDate You ArrivedReason
1.  
2.  
3.  
4.  
5.  

2.   Have you been to the emergency room since you left the hospital on {discharge date}? These would be emergency room visits that did not cause you to be admitted to the hospital (so you stayed in the emergency room the entire time and went home from the emergency room).

1___ Yes   2___ No

If YES, please fill out the table below for each emergency room visit. List the hospital, date of arrival, and reason for each visit.

HospitalDate You ArrivedReason
1.  
2.  
3.  
4.  
5.  

APPOINTMENTS

These next questions are about any appointments you had after you left the hospital on {discharge date}.

3.   Do you have a particular doctor's office, clinic, health center, or other place that you usually go to if you are sick or need advice about your health?

1___ Yes   2___ No

4.   Since you left the hospital on {discharge date}, have you seen your medical provider, sometimes called a primary care provider (or someone in their office)?

1___ Yes   2___ No

If YES, What date did you see this person? _______________________________________

DIAGNOSIS

5.   During your hospital stay, the doctors and nurses may have told you the name of your primary diagnosis or main problem. Do you know what your main problem was?

1___ Yes   2___ No   3___ N/A, reason: _________________________________________________

If YES, Can you please list the name of your primary diagnosis or main problem? _____________________________________________________________________________

These next questions ask about your visit at {hospital name} from {admit date} to {discharge date}.

YOUR HOSPITAL STAY

6.   During this hospital stay, how often did nurses treat you with courtesy and respect?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

7.   During this hospital stay, how often did nurses listen carefully to you?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

8.   During this hospital stay, how often did nurses explain things in a way you could understand?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

9.   During this hospital stay, how often did doctors treat you with courtesy and respect?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

10.  During this hospital stay, how often did doctors listen carefully to you?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

11.  During this hospital stay, how often did doctors explain things in a way you could understand?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

12.  During this hospital stay, how often were your questions answered to your satisfaction?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

13.  How often did hospital staff listen to you when they decided the plan for your care?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

MEDICINES

14.  During this hospital stay, were you told to take any medicine after you left the hospital? Include prescription and nonprescription medicines as well as any medicines you were already taking before your hospital stay.

1___ Yes   2___ No → If No, Go to Question 21

15.  During this hospital stay, did hospital staff explain the purpose of each of the medicines you were to take at home?

1___ Yes   2___ No → If No, Go to Question 17

16.  Was the explanation of each medicine's purpose easy to understand?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

17.  During this hospital stay, did hospital staff explain how much to take of each medicine and when to take it when you were at home?

1___ Yes   2___ No → If No, Go to Question 19

18.  How often was their explanation of how and when to take each medicine easy to understand?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

19.  During this hospital stay, did hospital staff ask you to describe how much you would take of each medicine and when you would take it when you were at home?

1___ Yes   2___ No

20.  During this hospital stay, did hospital staff tell you whom to call after you left the hospital if you had questions about your medicines?

1___ Yes   2___ No

21.  During this hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital?

1___ Yes   2___ No

22.  During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

1___ Yes   2___ No → If No, Go to Question 24

23.  Were these written instructions easy to understand?

1___ Yes   2___ No

WHEN YOU LEFT THE HOSPITAL

24.  After you left the hospital, did you go directly to your own home, to someone else's home, or to another health facility?

1___ Own home
2___ Someone else's home
3___ Another health facility

25.  After you left the hospital, did someone from the hospital call you to check how you were doing?

1___             Yes   2___ No → If No, Go to Question 27

If YES, please tell me how much you agree with the following statement:

26.  After the call, all of my questions about my medical care were answered.

___ Strongly disagree
___ Disagree
___ Agree
___ Strongly Agree

OVERALL RATING OF HOSPITAL

27.  Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

_________ (0-10)

28.  Would you recommend this hospital to your friends and family?

___ Definitely no
___ Probably no
___ Probably yes
___ Definitely yes

29.  Did you feel that your family and you were treated with respect?

1___ Yes   2___ No

ABOUT YOU

There are only a few remaining items left.

30.  What is your age?

1___ 18-30 years
2___ 31-50 years
3___ 51-70 years
4___ 71-above years

31.  In general, how would you rate your overall health?

1___ Excellent
2___ Very good
3___ Good
4___ Fair
5___ Poor

32.  What is the highest grade or level of school that you have completed?

1___ Some elementary or high school but did not graduate
2___ High school graduate or GED
3___ Some college or 2-year degree
4___ 4-year college graduate

33.  Are you of Spanish, Hispanic, or Latino origin or descent?

1___ No, not Spanish/Hispanic/Latino
2___ Yes

34.  How would you describe your race? Please choose one or more.

1___ White
2___ Black or African American
3___ Asian
4___ Native Hawaiian or Other Pacific Islander
5___ American Indian or Alaska Native

35.  What language do you mainly speak at home?

1___ English
2___ Spanish
3___ Some other language (please print): ___________________________________________

 

THANK YOU

Please return the completed survey in the postage-paid envelope.

Current as of March 2013
Internet Citation: Patient Outcome Survey (mailed version): Re-Engineered Discharge (RED) Toolkit. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/ptoutcome-mail.html