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Questionnaire template

Post-Discharge Patient Follow-Up

Measures recently discharged patients' views of their hospital stay, discharge process and problems after going home.

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Healthcare · Patient. All Healthcare templates

Questions in this template

Your Hospital Stay

  1. Thank you for helping us after your recent hospital stay. Your feedback shows us how to improve care and support for patients going home.

  2. Overall, how would you rate your most recent stay in our hospital?

    Choose one:

    • Very poor
    • Poor
    • Neutral
    • Good
    • Very good

  3. How would you rate each of these during your stay?

    • Medical care
    • Cleanliness
    • How quickly staff responded to you
    • Food

    For each row: choose one:

    • Very poor
    • Poor
    • Neutral
    • Good
    • Very good

Leaving Hospital

  1. Before you left, did a member of staff go through your discharge plan with you?

    Choose one:

    • Yes
    • No
    • I don't remember

  2. What did that conversation cover? (optional)

    Condition: Shown when the plan was discussed

    Open answer

  3. Were you given written instructions or information to take home?

    Choose one:

    • Yes
    • No
    • I don't remember

Since Going Home

  1. Since leaving hospital, have you had any of these problems?

    • Understanding how to take your medicines
    • Looking after yourself day to day
    • Getting transport to follow-up appointments
    • Health problems you did not expect

    For each row: choose one:

    • Yes
    • Not sure
    • No

  2. Tell us about any other difficulties you have had since going home. (optional)

    Open answer

Improving Care

  1. What could we do differently to improve your stay and your discharge? (optional)

    Open answer