CMS-10500 OAS CAHPS (Web Survey Screenshots)

Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS) Survey (CMS-10500)

Attachment C - Web Questionnaire [07-31-2018]

Patient Records

OMB: 0938-1240

Document [docx]
Download: docx | pdf

Web Interview Screenshots
for the Outpatient and Ambulatory Surgery CAHPS Survey

(OAS CAHPS®)

INTRO1 – IF NO DATE OF BIRTH MATCH, GO TO CONFIRM

OAS CAHPS® Survey

Thank you for participating in the Outpatient and Ambulatory Surgery CAHPS Survey. To ensure privacy, please enter [NAME]’s date of birth to access the survey.

Shape1

MM/DD/YYYY





According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1240. Expiration date _/_/_.The time required to complete this information collection is estimated to average 8 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


Next>



Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

CONFIRM – If yes, continue. If no, go to Q_INELIG

OAS CAHPS® Survey

That date of birth does not match our records. To ensure we have the correct record, please confirm if you had an outpatient surgery or procedure at [FACILITY NAME] on [DATE].

    • Yes

    • No


Next>



Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

INTRO2

OAS CAHPS® Survey

[FACILITY NAME] is participating in a survey about patients’ experiences with outpatient surgeries and procedures. The results will be used to help [FACILITY NAME] understand patient experiences in their facilities.

Your participation in this survey is completely voluntary and will not affect any health care or benefits you receive. All information you provide is confidential and is protected by the Privacy Act.


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.







INTRO3

OAS CAHPS® Survey

This survey asks about your experience at [FACILITY NAME]. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure. Please answer these questions only for the procedure you had on [DATE]. Do not include any other procedures in your answers.



The first few questions are about getting ready for your procedure. Include any information you received before and on the day of your procedure.


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Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q1

OAS CAHPS® Survey
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  1. BEFORE YOUR PROCEDURE



Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure?

    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.




Q2

OAS CAHPS® Survey
Shape3

  1. BEFORE YOUR PROCEDURE



Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q3

OAS CAHPS® Survey
Shape4

  1. ABOUT THE FACILITY AND STAFF

The next questions ask about the day of your procedure.



Did the check-in process run smoothly?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q4

OAS CAHPS® Survey
Shape5

  1. ABOUT THE FACILITY AND STAFF



Was the facility clean?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q5

OAS CAHPS® Survey
Shape6

  1. ABOUT THE FACILITY AND STAFF



Were the clerks and receptionists at the facility as helpful as you thought they should be?


    • Yes, definitely

    • Yes, somewhat

    • No


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Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q6

OAS CAHPS® Survey
Shape7

  1. ABOUT THE FACILITY AND STAFF



Did the clerks and receptionists at the facility treat you with courtesy and respect?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q7

OAS CAHPS® Survey
Shape8

  1. ABOUT THE FACILITY AND STAFF



Did the doctors and nurses treat you with courtesy and respect?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q8

OAS CAHPS® Survey
Shape9

  1. ABOUT THE FACILITY AND STAFF



Did the doctors and nurses make sure you were as comfortable as possible?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q9

OAS CAHPS® Survey
Shape10

  1. COMMUNICATIONS ABOUT YOUR PROCEDURE

As a reminder, please include any information you received before and on the day of the procedure.


Did the doctors and nurses explain your procedure in a way that was easy to understand?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q10 LOGIC AFTER: IF Q10 = NO THEN GO TO Q13

OAS CAHPS® Survey
Shape11

  1. COMMUNICATIONS ABOUT YOUR PROCEDURE



Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia?


    • Yes

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q11

OAS CAHPS® Survey
Shape12

  1. COMMUNICATIONS ABOUT YOUR PROCEDURE



Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q12

OAS CAHPS® Survey
Shape13

  1. COMMUNICATIONS ABOUT YOUR PROCEDURE



Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q13

OAS CAHPS® Survey
Shape14

  1. COMMUNICATIONS ABOUT YOUR PROCEDURE



Discharge instructions include things like symptoms you should watch for after your procedure, instructions about medicines, and home care. Before you left the facility, did you receive written discharge instructions?


    • Yes

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q14

OAS CAHPS® Survey
Shape15

  1. YOUR RECOVERY


Did your doctor or anyone from the facility prepare you for what to expect during your recovery?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q15

OAS CAHPS® Survey
Shape16

  1. YOUR RECOVERY



Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure?


    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q16

OAS CAHPS® Survey
Shape17

  1. YOUR RECOVERY



At any time after leaving the facility, did you have pain as a result of your procedure?



    • Yes

    • No


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Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q17

OAS CAHPS® Survey
Shape18

  1. YOUR RECOVERY



Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting?



    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q18

OAS CAHPS® Survey
Shape19

  1. YOUR RECOVERY



At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?



    • Yes

    • No


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Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q19

OAS CAHPS® Survey
Shape20

  1. YOUR RECOVERY



Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure?



    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q20

OAS CAHPS® Survey
Shape21

  1. YOUR RECOVERY



At any time after leaving the facility, did you have bleeding as a result of your procedure?



    • Yes

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q21

OAS CAHPS® Survey
Shape22

  1. YOUR RECOVERY



Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection?



    • Yes, definitely

    • Yes, somewhat

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q22

OAS CAHPS® Survey
Shape23

  1. YOUR RECOVERY



At any time after leaving the facility, did you have any signs of infection?



    • Yes

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.


Q23

OAS CAHPS® Survey
Shape24

  1. YOUR OVERALL EXPERIENCE


Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?



Flowchart: Connector 200_0 Worst Facility

Flowchart: Connector 201_0

Flowchart: Connector 202_0

Flowchart: Connector 203_0

Flowchart: Connector 204_0

Flowchart: Connector 205_0

Flowchart: Connector 206_0

Flowchart: Connector 207_0

Flowchart: Connector 208_0

Flowchart: Connector 210_0

Flowchart: Connector 211_0 Best Facility

0

1

2

3

4

5

6

7

8

9

10









Flowchart: Connector 209_0







<Back



Next>



Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q24

OAS CAHPS® Survey
Shape25

  1. YOUR OVERALL EXPERIENCE



Would you recommend this facility to your friends and family?



    • Definitely no

    • Probably no

    • Probably yes

    • Definitely yes


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.


Q25

OAS CAHPS® Survey
Shape26

  1. ABOUT YOU



In general, how would you rate your overall health?



    • Excellent

    • Very good

    • Good

    • Fair

    • Poor


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.


Q26

OAS CAHPS® Survey
Shape27

  1. ABOUT YOU



In general, how would you rate your overall mental or emotional health?



    • Excellent

    • Very good

    • Good

    • Fair

    • Poor


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.




Q27

OAS CAHPS® Survey
Shape28

  1. ABOUT YOU


What is your age?


  • 18 to 24

  • 25 to 34

  • 35 to 44

  • 45 to 54

  • 55 to 64

  • 65 to 74

  • 75 to 79

  • 80 to 84

  • 85 or older


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q28

OAS CAHPS® Survey
Shape29

  1. ABOUT YOU



Are you male or female?

    • Male

    • Female


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.


Q29

OAS CAHPS® Survey
Shape30

  1. ABOUT YOU


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


  • 8th grade or less

  • Some high school, but did not graduate

  • High school graduate or GED

  • Some college or 2-year degree

  • 4-year college graduate

  • More than 4-year college degree


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q30 LOGIC AFTER: IF Q30 = NO THEN GO TO Q32

OAS CAHPS® Survey
Shape31

  1. ABOUT YOU



Are you of Hispanic, Latino, or Spanish origin?



    • Yes, Hispanic, Latino, or Spanish

    • No, not Hispanic, Latino, or Spanish


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q31

OAS CAHPS® Survey
Shape32

  1. ABOUT YOU


Which group best describes you?


  • Mexican, Mexican American, Chicano

  • Puerto Rican

  • Cuban

  • Another Hispanic, Latino, or Spanish origin


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q32

OAS CAHPS® Survey
Shape33

    1. ABOUT YOU



What is your race? You may select one or more categories.



Shape34

White

Shape35

Black or African American

Shape36

American Indian or Alaska Native

Shape37

Asian

Shape38

Native Hawaiian or Pacific Islander

Shape39

None of the above


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q32a PRELOGIC: IF Q32 = ASIAN, ASK Q32a; ELSE, GO TO Q33

OAS CAHPS® Survey
Shape40

  1. ABOUT YOU


Which groups best describe you? You may select one or more categories.


Shape41

Asian Indian

Shape42

Chinese

Shape43

Filipino

Shape44

Japanese

Shape45

Korean

Shape46

Vietnamese

Shape47

Other Asian

NONE OF THE ABOVE


Shape48 <Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q32b PRELOGIC: IF Q32 = HAWAIIAN, ASK Q32b ELSE, GO TO Q33.

OAS CAHPS® Survey
Shape49

  1. ABOUT YOU


Which groups best describe you? You may select one or more categories.


Shape50

Shape51

Native Hawaiian

Shape52

Guamanian or Chamorro

Shape53

Samoan

Shape54

Other Pacific Islander

NONE OF THE ABOVE


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.

Q33

OAS CAHPS® Survey
Shape55

  1. ABOUT YOU



How well do you speak English?


  • Very well

  • Well

  • Not well

  • Not at all


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q34 LOGIC AFTER: IF Q34 = NO THEN GO TO Q36

OAS CAHPS® Survey
Shape56

  1. ABOUT YOU



Do you speak a language other than English at home?



    • Yes

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.





Q35

OAS CAHPS® Survey
Shape57

  1. ABOUT YOU



What is that language?



Shape58

    • Spanish

    • Other Language (Please specify):


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q36 LOGIC AFTER: IF Q36 = NO THEN GO TO Q_END

OAS CAHPS® Survey
Shape59

  1. ABOUT YOU



Did someone help you complete this survey?



    • Yes

    • No


<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.





Q37

OAS CAHPS® Survey
Shape60

  1. ABOUT YOU



Shape61

How did that person help you? Check all that apply.

Shape62

Read the questions to me

Shape63

Wrote down the answers I gave

Shape64

Answered the questions for me

Shape66 Shape65

Translated the questions into my language

Helped in some other way (Please explain):

Shape67



No one helped me complete this survey







<Back


Next>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q_END

OAS CAHPS® Survey



You have completed the OAS CAHPS Survey. Thank you for your time.


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Submit>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.



Q_INELIG PRELOGIC: DOB DOES NOT MATCH WHAT WE HAVE ON FILE AND CONFIRM=NO

OAS CAHPS® Survey



Thank you for your time. Looks like you are not the person we need to compete this survey.


<Back


End>


Questions? Contact the OAS CAHPS Survey Coordination Team at oascahps@rti.org or call 1-866-590-7468.







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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleProtocols and Guidelines Manual
SubjectHome Health Care CAHPS Survey
Authordoc prep
File Modified0000-00-00
File Created2021-01-20
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