Health Literacy Universal Precautions Toolkit, 2nd Edition

Patient Portal Feedback Form

[Microsoft Word file Microsoft Word version - 24.42 KB]

These questions can be used as a guide to collect feedback as you observe a patient using your portal. Use this form to record responses.

  1. Is this the first time you have visited our Patient Portal?
     ___  Yes
     ___  No

     If Yes: Why haven't you used the patient portal before? ______________________________
     ___________________________________________________________________________
     ___________________________________________________________________________

  1. How often do you use the Internet?
     ___  Every day
     ___  A few times per week
     ___  About once per week
     ___  Less than once per week
     ___  Never or hardly ever
  1. Is it clear how to sign in to the patient portal?
     ___  Yes
     ___  No. If No, what can we do to make it clearer? _______________________________
     ________________________________________________________________________
     ________________________________________________________________________
  1. Does the menu of items on the home page give you the options you need?
     ___  Yes
     ___  No. If No, what do you need to do and cannot find on the home page? ___________
     ________________________________________________________________________
     ________________________________________________________________________
  1. Do you like how the site looks?
     ___  Yes
     ___  No. If No, how could we improve its appearance? ____________________________
     ________________________________________________________________________
     ________________________________________________________________________
TO STAFF: Allow the patient to navigate the site. Ask if he or she could show you how to do something the patient is likely to want to do while on the practice portal (for instance, try to request a prescription refill or make an appointment). Once this is done, ask the following questions.
  1. Is the information you want on the site?
     ___  Yes
     ___  No. If no, what information would you like to have on the site?  ________________
     ________________________________________________________________________
  1. Is it easy to find the information you want?
     ___  Yes
     ___  No. If no, what was hard to find and why? __________________________________
     ________________________________________________________________________
     ________________________________________________________________________
  1. Is the information on the site easy to understand?
     ___  Yes
     ___  No. If no, what was hard to understand and why? ____________________________
     ________________________________________________________________________
     ________________________________________________________________________
  1. Is the information on the site clearly displayed (i.e., easy to see and read)?
     ___  Yes
     ___  No. If no, what was unclear and why? _____________________________________
     ________________________________________________________________________
     ________________________________________________________________________
  1. Now that we have gone through the patient portal, would you use it again?

     ___  Yes
     ___  No. If no, why not? ___________________________________________________
     ________________________________________________________________________
     ________________________________________________________________________

Use this space to note how easy it was for the patient to perform a task you ask him or her to do (e.g., find information on a particular topic, look up recent lab results, request a prescription refill).
 

 

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Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Patient Portal Feedback Form. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool17b.html