| Date form completed : * |
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| Patient name : * |
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| Admission date : * |
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| Discharge date : * |
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Admission and IPD Services
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| How do you evaluate the admission process and pre-admission coordination? : * | |
| How do you evaluate the courtesy and respect of the staff of the International Patients Unit? : * | |
| How do you evaluate the responsiveness and follow-up of the IPD staff? : * | |
| Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied No comment : * | |
| How do you evaluate the information provided about treatment costs? : * | |
| How do you evaluate the ease of communication with staff and receiving translation services? : * | |
| How do you evaluate the coordination of various services for you by the IPD unit : * | |
Medical and Nursing Services
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| How do you evaluate the courtesy and respect of the attending physician : * | |
| How do you evaluate your satisfaction with the attending physician’s visits and responsiveness : * | |
| How do you evaluate the physician’s explanation about the illness, treatment measures, and treatment process : * | |
| How do you evaluate the courtesy and respect of the nurses? : * | |
| How do you evaluate nurses’ timely presence when services are needed : * | |
| How do you evaluate the provision of nursing care : * | |
| How do you evaluate staff responsiveness to your requests and needs : * | |
Diagnostic, Therapeutic, and Paraclinical Services
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| How do you evaluate the speed and coordination in providing diagnostic and therapeutic services : * | |
| How do you evaluate the provision of needed paraclinical services : * | |
| How do you evaluate the quality of the medical and specialty services provided : * | |
| How do you evaluate the information provided about the results of diagnostic and therapeutic procedures : * | |
Environment and Welfare Services
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| How do you evaluate the cleanliness and hygiene of the ward environment : * | |
| How do you evaluate the welfare and accommodation facilities available in the ward : * | |
| How do you evaluate the condition of the room and available facilities : * | |
| How do you evaluate the quality and variety of breakfast : * | |
| How do you evaluate the quality and variety of lunch : * | |
| How do you evaluate the quality and variety of dinner : * | |
| How do you evaluate the timing of food serving : * | |
Patient Rights and Discharge
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| How do you evaluate the extent to which your privacy was respected during the provision of services : * | |
| How do you evaluate the respect shown for your culture, values, and cultural needs : * | |
| How do you evaluate your satisfaction with the information and necessary education provided at discharge : * | |
| How do you evaluate the coordination and follow-up of the continuation of the treatment process after discharge : * | |
| How do you evaluate the coordination and follow-up of your treatment after discharge : * | |