Patient Satisfaction Questionnaire

We are pleased that NW Surgery Center was chosen for your surgical procedure. We wish you well on your recovery and hope that your stay was as pleasant as possible. In order that we may continue to assure the highest quality patient care, we need your assistance. Please take a moment and complete this questionnaire.   1. Instructions before the day of surgery adequately prepared me for my surgery.   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 2. Questions about financial arrangements were answered courteously and in a manner I understood clearly.   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 3. The admitting process was prompt and and the admitting staff courteous.   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 4. The NW Surgery Center nursing staff was respectful and responsive to my needs.   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 5. The facility was clean and comfortable.     Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 6. A member of Anesthesia explained the anesthetic I would be receiving thoroughly and to my satisfaction   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 7. Throughout my stay it was evident that the staff was concerned about my care and comfort.   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 8. Instructions for care at home were clearly and thoroughly explained to me by the nursing staff.   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 9.  My physician explained my procedure clearly and answered all my questions.   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor 10. The staff members at NW Surgery Center were professional and helpful.   Select One 5 - Excellent 4 - Above Average 3 - Average 2 - Below Average 1 - Poor         Did you experience any unexpected problems after your procedure? If yes please explain:   Select One Yes No       Is there anything we could have done to make your stay with us more comfortable? If yes please explain:   Select One Yes No             I would recommend NW Surgery Center.   Select One Yes No   If I need surgery again, I would ask my physician about coming to NW Surgery Center.   Select One Yes No         We welcome your comments and suggestions.       Name:   (optional/confidential)   Date of Surgery:     Surgeon:           Comments:

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