ATTACHMENT B
ER Patient Experience Survey – Admitted to Hospital Stand Alone Version (57 items)
Please answer the questions in this survey about the care you got from the hospital emergency room on or around the date named below.
[Name of emergency room / DATE OF VISIT label goes here]
All of the questions in the survey will ask about your emergency room visit only. Please do not think about care you received after you were admitted to the hospital.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is XXX-XXXX. The time required to complete this information collection is estimated to average 13 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Answer each question by circling your response.
You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:
Yes If Yes, go to #1 on page 1
No
GOING TO THE EMERGENCY ROOM
1. Thinking about this visit, what was the main reason why you went to the emergency room?
An accident or injury
A new health problem
An ongoing health condition or concern
2. For this visit, did you go to the emergency room in an ambulance?
Yes
No
3. When you first arrived at the emergency room, how long was it before someone talked to you about the reason why you were there?
Less than 5 minutes
5 to 15 minutes
More than 15 minutes
4. Using any number from 0 to 10, where 0 is not at all important and 10 is extremely important, when you first arrived at the emergency room, how important was it for you to get care right away?
0 – not at all important
1
2
3
4
5
6
7
8
9
10 – extremely important
DURING YOUR EMERGENCY ROOM VISIT
5. During this emergency room visit, did someone let you know about how long you would wait before you got care for the first time?
Yes, definitely
Yes, somewhat
No
6. During this emergency room visit did you get care within 30 minutes of getting to the emergency room?
Yes
No
7. During this emergency room visit, did you have a family member or friend with you?
Yes
No If No, go to Question 9
8. During this emergency room visit, was your family member or friend allowed to stay with you when you wanted them with you?
Yes, definitely
Yes, somewhat
No
9. During this emergency room visit, did the doctors or nurses ask about all of the medicines you were taking?
Yes, definitely
Yes, somewhat
No
10. During this emergency room visit, were you given any medicine that you had not taken before?
Yes
Don’t Know
No If No, go to Question 13
11. Before giving you any new medicine, did the doctors or nurses tell you what the medicine was for?
Yes, definitely
Yes, somewhat
No
12. Before giving you any new medicine, did the doctors or nurses describe possible side effects to you in a way you could understand?
Yes, definitely
Yes, somewhat
No
13. During this emergency room visit, did you have any pain?
Yes, definitely
Yes, somewhat
No If No, go to Question 16
14. During this emergency room visit, did you get medicine for pain?
Yes, definitely
Yes, somewhat
No
15. During this emergency room visit, did the doctors and nurses do everything they could to help you with your pain?
Yes, definitely
Yes, somewhat
No
16. An interpreter is someone who helps you talk with others who do not speak your language. During this emergency room visit, did you need an interpreter?
Yes
No If No, go to Question 18
17. During this emergency room visit, when you needed an interpreter did you get one?
Yes
No
PEOPLE WHO TOOK CARE OF YOU IN THE EMERGENCY ROOM
Please answer the following questions about the people who took care of you while you were in the emergency room. Do not include doctors, nurses, or hospital staff who took care of you after you were admitted to the hospital and moved to another part of the hospital for more care.
18. During this emergency room visit, how often did doctors, nurses, or emergency room staff introduce themselves to you the first time they came to take care of you?
Never
Sometimes
Usually
Always
19. During this emergency room visit, were you kept informed about who was in charge of your care?
Yes, definitely
Yes, somewhat
No
20. During this emergency room visit, how often did nurses treat you with courtesy and respect?
Never
Sometimes
Usually
Always
21. During this emergency room visit, how often did nurses listen carefully to you?
Never
Sometimes
Usually
Always
22. During this emergency room visit, how often did nurses explain things in a way you could understand?
Never
Sometimes
Usually
Always
23. During this emergency room visit, did nurses spend enough time with you?
Yes, definitely
Yes, somewhat
No
24. During this emergency room visit, how often did doctors treat you with courtesy and respect?
Never
Sometimes
Usually
Always
25. During this emergency room visit, how often did doctors listen carefully to you?
Never
Sometimes
Usually
Always
26. During this emergency room visit, how often did doctors explain things in a way you could understand?
Never
Sometimes
Usually
Always
27. During this emergency room visit, did doctors spend enough time with you?
Yes, definitely
Yes, somewhat
No
LEAVING THE EMERGENCY ROOM
28. Once you found out you would have to stay in the hospital, were you kept informed about how long it would be before you went to another part of the hospital?
Yes, definitely
Yes, somewhat
No
29. Before you left the emergency room, did you understand why you needed to stay in the hospital?
Yes, definitely
Yes, somewhat
No
OVERALL EXPERIENCE
Please answer the following questions about your visit to the emergency room named on the front of the survey. Do not include any other emergency room visits or care you got after you were admitted to the hospital and moved to another part of the hospital for more care.
30. Using any number from 0 to 10, where 0 is the worst care possible and 10 is the best care possible, what number would you use to rate your care during this emergency room visit?
0 – worst care possible
1
2
3
4
5
6
7
8
9
10 – best care possible
31. Would you recommend this emergency room to your friends and family?
Definitely no
Probably no
Probably yes
Definitely yes
YOUR HEALTH CARE
32. Thinking about the 30 days before this visit, how many times did you go to this emergency room to get care for yourself for any reason? Please include the emergency room visit you have been answering questions about in this survey.
1 time
2 times
3 times
4 or more times
33. In the last 6 months, how many times have you visited any emergency room to get care for yourself? Please include the emergency room visit you have been answering questions about in this survey.
1 time
2 times
3 times
4 times
5 to 9 times
10 or more times
34. Not counting the emergency room, is there a doctor’s office, clinic, or other place you usually go if you need a check-up, want advice about a health problem, or get sick or hurt?
Yes
No If No, go to Question 36
35. How many times in the last 6 months did you visit that doctor’s office, clinic, health center, or other place to get care or advice about your health?
None
1 time
2
3
4
5 to 9
10 or more times
ABOUT YOU
There are only a few questions left.
36. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
37. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
38. In the last 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?
Yes
No If No, go to Question 40
39. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
40. Do you now need or take medicine prescribed by a doctor?
Yes
No If No, go to Question 42
41. Is this medicine to treat a condition that has lasted for at least 3 months?
Yes
No
42. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
43. Are you male or female?
Male
Female
44. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
45. Are you of Hispanic, Latino/a, or Spanish origin?
Yes, Hispanic, Latino/a, or Spanish
No, not Hispanic, Latino/a, or Spanish If No, go to Question 47
46. Which group best describes you?
Mexican, Mexican American, Chicano/a
Puerto Rican
Cuban
Another Hispanic, Latino/a, or Spanish origin
47. What is your race? Mark one or more.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
48. What language do you mainly speak at home?
English
Spanish
Chinese
Some other language (please print): .
49. Are you deaf or do you have serious difficulty hearing?
Yes
No
50. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Yes
No
51. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Yes
No
52. Do you have serious difficulty walking or climbing stairs?
Yes
No
53. Do you have difficulty dressing or bathing?
Yes
No
54. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
Yes
No
55. Did someone help you complete this survey?
Yes
No Thank you.
Please return the completed survey in the postage-paid envelope.
56. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Please print:
57. Was the person who helped you with you at any time during this emergency room visit?
Yes
No
Thank
you
Please return the completed survey in the postage-paid envelope.
ER Patient Experience Survey – Admitted to Hospital (Stand Alone)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |