0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle

Form Approved
OMB Form No. 0917-0036
Expiration Date:

Adult Care Unit (ACU) Patient Experience Survey
Male: _____

Female: ____

Age: ______

Please rate the following statements using numbers
1-5 based on this scale. Circle your answers.

Date of Discharge: ___________________

1
Strongly
Disagree
1

2
Disagree

3
Unsure

4
Agree

2

3

4

5
Strongly
Agree
5

1

2

3

4

5

1.

I would recommend this hospital to my family and friends.

2.

Usually, my health is good.

3.

I am sure I can take care of my health. (T’áá hwó’ají t’éego)

1

2

3

4

5

4.

Overall, I was pleased with how my pain was treated.
Check box if no pain
I felt safe during my stay at Chinle Hospital.

1

2

3

4

5

1

2

3

4

5

The staff was polite and treated me and my family with
respect.
My room was regularly kept clean and organized.

1

2

3

4

5

1

2

3

4

5

5.
6.
7.
8.

The nurses explained medications, my illness, treatment and
plan of care.
The staff answered my call light within 1-2 minutes.

1

2

3

4

5

1

2

3

4

5

10. I was pleased with the care I received from the nursing staff.

1

2

3

4

5

11. I was pleased with the care I received from the doctors.

1

2

3

4

5

12. The nurse asked me my name before giving any medications.

1

2

3

4

5

13. The nurse checked my wristband before giving any
medications.
14. The nurse and/or lab tech asked me my name before drawing
blood.
15. The nurse and/or lab tech check my wristband before drawing
blood.
16. I felt ready for discharge from the hospital.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

17. I was pleased with the speed of discharge process from the
hospital.
18. I was given instructions how to care for myself at home.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

9.

19. After talking to the pharmacist, I clearly understood the
purpose of taking each of my medication.
20. I can repeat what the pharmacist told me about my
medications.
21. Using a number from 0-10, where 0 is the worst possible and
10 is the best possible, what number would you choose to
rate all your health care during your hospital stay?

0

1

2

3

4

5

6

7

8

9

10

What did we do well? ________________________________________________________________________________
__________________________________________________________________________________________________
What can we do better? ______________________________________________________________________________
__________________________________________________________________________________________________

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