Medical Practice Survey

Formed Approved
OMB No. 0920-0953
Exp. Date 12/31/2015

MEDICAL PRACTICE SURVEY
We thank you in advance for completing this questionnaire. When you have finished, please mail it in the
enclosed envelope.

Please rate your visit on/with:

BACKGROUND QUESTIONS
1. If someone other than the patient is
completing this survey, please fill in circle:
2. Was this your first visit here?....

Yes

No

4. How many minutes did you wait in
the exam room before you were
seen by a doctor, physician
assistant (PA), nurse practitioner
(NP), or midwife? .........................

minutes

3. How many minutes did you wait
after your scheduled appointment
time before you were called to
an exam room?............................
minutes

INSTRUCTIONS: Please rate the medical practice services you received from the
North Shore LIJ Health System. Select the response that best describes your
experience. If a question does not apply to you, please skip to the next question.
Space is provided for you to comment on good or bad things that may have
happened to you.

very
very
poor poor fair good good

ACCESS
1.
2.
3.
4.

Please use black or blue ink to
fill in the circle completely.
Example:

1

2

3

4

5

Ease of getting through to the practice on the phone ...................................................
Convenience of our office hours ...................................................................................
Ease of scheduling your appointment ..........................................................................
Courtesy of staff in the registration area .......................................................................

Comments (describe good or bad experience):

MOVING THROUGH YOUR VISIT

very
very
poor poor fair good good

1

2

3

4

5

1. If you experienced delays, degree to which you were informed about these delays ...
2. Wait time at practice (from scheduled appointment time to leaving)............................
Comments (describe good or bad experience):

NURSE/ASSISTANT/TECHNICIAN/NON-MD STAFF

very
very
poor poor fair good good

1

2

3

4

5

1. Friendliness/courtesy of the staff...................................................................................
2. Concern the staff showed for your problem ..................................................................
Comments (describe good or bad experience):

Draft

Public reporting burden of this collection of information is estimated to average 4 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance
Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).

continued...

CARE PROVIDER

very
very
poor poor fair good good

1

2

3

4

5

DURING YOUR VISIT, YOUR CARE WAS PROVIDED PRIMARILY BY A DOCTOR, PHYSICIAN
ASSISTANT (PA), NURSE PRACTITIONER (NP), OR MIDWIFE.
PLEASE ANSWER THE FOLLOWING QUESTIONS WITH THAT HEALTH CARE PROVIDER IN MIND.

Complete this section only if your visit was to be seen by your care provider, otherwise
leave this section blank.
1. Friendliness/courtesy of the care provider....................................................................
2. Explanations the care provider gave you about your problem or condition..................
3. Concern the care provider showed for your questions or worries ................................
4. Care provider's efforts to include you in decisions about your treatment.....................
5. Information the care provider gave you about medications (if any)..............................
6. Instructions the care provider gave you about follow-up care (if any) ..........................
7. Degree to which care provider talked with you using words you could understand .....
8. Amount of time the care provider spent with you..........................................................
9. Your confidence in this care provider ...........................................................................
10. Likelihood of your recommending this care provider to others ....................................
Comments (describe good or bad experience):

PERSONAL ISSUES
1.
2.
3.
4.

very
very
poor poor fair good good

1

2

3

4

5

How well staff protected your safety (by washing hands, wearing gloves, etc.)...........
Our sensitivity to your needs .........................................................................................
Our concern for your privacy.........................................................................................
Cleanliness of our practice............................................................................................

Comments (describe good or bad experience):

ELECTRONIC MEDICAL RECORD

very
very
poor poor fair good good

1

2

3

4

5

1. Degree to which having an electronic medical record system (computer) in the
room makes your interactions with the provider easier.................................................
2. Effect of electronic medical record system on the length of your visit ..........................
3. Degree to which your care is improved because of the electronic medical record ......
Comments (describe good or bad experience):

OVERALL ASSESSMENT

very
very
poor poor fair good good

1. How well the staff worked together to care for you.......................................................
2. Likelihood of your recommending our practice to others .............................................
Comments (describe good or bad experience):

Patient's Name: (optional)
Telephone Number: (optional)

© 2004 PRESS GANEY ASSOCIATES, INC.,
All Rights Reserved
CL#12062-MD0104-02-06/11

Draft

1

2

3

4

5