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pdfAnticoagulation (Warfarin/Coumadin)
Patient Satisfaction Survey
2900-xxxx
Estimated Burden 7 minutes
VA Form 10-211002
PRA Statement: This information is collected in accordance with section 3507 of the Paperwork
Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required
to respond to a collection of information unless it displays a valid OMB number. We anticipate
that the time expended by all individuals who participate in this survey will average 7
minutes. Your participation is voluntary and failure to furnish information will have no effect on
any entitlement to benefits.
May 2013
Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
Welcome to the Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
Thank you for taking the time to complete this survey, it should take you 7 minutes. Completing this survey is
voluntary. The results are not intended to be made public, but to improve anticoagulation (warfarin/Coumadin) services
that are provided to the veterans of New England. You have been selected for this survey because you are receiving
anticoagulation (warfarin/Coumadin) services at a VA Medical Center in New England.
*Which VA Medical Center do you visit most of the time? (This includes satellite clinics
associated with the main facility.)
j Bedford VA Medical Center
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j VA Boston Healthcare System
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j VA Central Western Massachusetts
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j VA Connecticut Healthcare System
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j VA Maine Healthcare System
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j Manchester VA Medical Center
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j Providence VA Medical Center
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j White River Junction VA Medical Center
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Anticoagulation Management
This section focuses on how your anticoagulation (warfarin/Coumadin) treatment is managed.
*Select where you have your blood sample taken for your anticoagulation
(warfarin/Coumadin) care most frequently:
j I visit the main VA medical center
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j I visit a satellite VA clinic (CBOC: communitybased outpatient clinic, outpatient clinic, outreach clinic)
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j I visit a nonVA lab (for example, Quest or Memorial Hospital)
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j Somone comes to my residence (visiting nurse, lab staff)
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j I am unsure
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*Select how your blood is drawn most frequently:
j Blood is drawn from my arm
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j Blood is drawn from my finger
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Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
*Select how your results and dosing instructions are communicated to you most
frequently:
j I have an inperson/facetoface visit
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j I receive a phone call
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j I call the clinic
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j I receive a letter
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j I communicate through My HealtheVet (www.myhealth.va.gov)
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Other (please specify)
Anticoagulation Treatment
We would like to know how your anticoagulation treatment (warfarin/Coumadin) affects you, what you know and how you
feel about your anticoagulation treatment. Please check the answer that best fits your situation. If a question does not
apply to you, then check “not at all.”
Considering anticoagulation (warfarin/Coumadin) treatment as a whole, please answer the
following.
How complicated is your anticoagulation
Not at all
A little
Somewhat
Moderately
Quite a bit
A lot
Very much
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reatment?
How timeconsuming is your
anticoagulation treatment?
How frustrating is your anticoagulation
treatment?
Compared to other treatments you have
had, how difficult is your anticoagulation
treatment to manage?
When you have anticoagulation (warfarin/Coumadin) treatment, you tend to bleed or
bruise more easily. You may limit your activities as a result. Limit means you do less of the
activity, or no longer perform the activity at all.
How much does anticoagulation treatment
Not at all
A little
Somewhat
Moderately
Quite a bit
A lot
Very much
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limit your ability to work for pay?
How much does anticoagulation treatment
limit your ability to care for dependent
family members (such as your child,
parent or spouse)?
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Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
Being on anticoagulation (warfarin/Coumadin) treatment means doing a lot of things,
some every day and some less often.
Overall, how much of a burden is your
Not at all
A little
Somewhat
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Quite a bit
A lot
Very much
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anticoagulation treatment?
How much of an inconvenience is it to
travel to the anticoagulation clinic?
How much of an inconvenience is it to
wait to be seen by the anticoagulation
pharmacist or other provider?
How much do your visits to the
anticoagulation clinic burden family
members or friends who accompany you
to your appointments?
These questions ask what you know and feel about your anticoagulation
(warfarin/Coumadin) treatment.
Overall, how satisfied are you with your
Not at all
A little
Somewhat
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Quite a bit
A lot
Very much
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anticoagulation treatment?
Overall, how confident are you about
managing your anticoagulation treatment
at home?
How well do you understand the medical
reason for your anticoagulation
treatment?
How likely would you be to recommend
this form of anticoagulation treatment to
someone else with your medical
condition?
Anticoagulation Treatment Preferences
These questions ask how you would prefer to receive anticoagulation (warfarin/Coumadin) treatment. All of these options
may not be available at the location you visit.
On a scale of 1 to 5, select your preference level for each blood sample collection method
with 1 being least preferred and 5 being most preferred.
1 (least preferred)
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5 (most preferred)
Blood drawn from my arm
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Blood drawn from my finger
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Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
On a scale of 1 to 5, select your preference level for each method of receiving your lab
results and dosing instructions with 1 being least preferred and 5 being most preferred.
1 (least preferred)
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5 (most preferred)
Inperson/facetoface visit
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Receive a phone call
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Call the clinic
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Receive a letter
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Communicate through My HealtheVet
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(www.myhealth.va.gov)
Please provide any additional comments or suggestions regarding your anticoagulation
(warfarin/Coumadin) treatment:
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| File Type | application/pdf |
| File Modified | 2013-05-20 |
| File Created | 2013-05-19 |