ATTACHMENT C
ER Patient Experience Survey – Admitted to Hospital (HCAHPS Add On) Version (39 items)
Please answer the questions in this survey about the care you got from the emergency room and hospital on or around the date named below.
[Name of HOSPITAL / DATE OF VISIT label goes here]
The first questions in the survey will ask about your emergency room visit. Later in the survey, you will be asked about your stay in the hospital immediately following your emergency room visit.
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 10 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
DURING YOUR EMERGENCY ROOM VISIT
4. 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
5. During this emergency room visit did you get care within 30 minutes of getting to the
emergency room?
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.
6. 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
7. During this emergency room visit, how often did nurses treat you with courtesy and respect?
Never
Sometimes
Usually
Always
8. During this emergency room visit, how often did doctors treat you with courtesy and respect?
Never
Sometimes
Usually
Always
9. 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
10. Before you left the emergency room, did you understand why you needed to stay in the
hospital?
Yes, definitely
Yes, somewhat
No
OVERALL EMERGENCY ROOM EXPERIENCE
11. 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
12. 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
YOUR CARE DURING YOUR HOSPITAL ADMISSION
For the rest of the questions, please think only about the care you received after you left the emergency room and went to another part of the hospital for more care.
13. During this hospital stay, how often did nurses treat you with courtesy and respect?
Never
Sometimes
Usually
Always
14. During this hospital stay, how often did nurses listen carefully to you?
Never
Sometimes
Usually
Always
15. During this hospital stay, how often did doctors explain things in a way you could
understand?
Never
Sometimes
Usually
Always
16. During this hospital stay, after you pressed the call button, how often did you get help as
soon as you wanted it?
Never
Sometimes
Usually
Always
I never pressed the call button
17. During this hospital stay, how often did doctors treat you with courtesy and respect?
Never
Sometimes
Usually
Always
18. During this hospital stay, how often did doctors listen carefully to you?
Never
Sometimes
Usually
Always
19. During this hospital stay, how often did doctors explain things in a way you could
understand?
Never
Sometimes
Usually
Always
20. During this hospital stay, how often were you room and bathroom kept clean?
Never
Sometimes
Usually
Always
21. During this hospital stay, how often was the area around your room quiet at night?
Never
Sometimes
Usually
Always
22. During this hospital stay, did you need help from nurses or other hospital staff in getting to
the bathroom or using a bedpan?
Yes
No If No, Go to Question 24
23. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
Never
Sometimes
Usually
Always
24. During this hospital stay, did you need medicine for pain?
Yes
No If No, Go to Question 27
25. During this hospital stay, how often was your pain well controlled?
Never
Sometimes
Usually
Always
26. During this hospital stay, how often did the hospital staff do everything they could to help
you with your pain?
Never
Sometimes
Usually
Always
27. During this hospital stay, were you given any medicine that you had not taken before?
Yes
No If No, Go to Question 30
28. Before giving you any new medicine, how often did hospital staff tell you what the medicine
was for?
Never
Sometimes
Usually
Always
29. Before giving you any new medicine, how often did hospital staff describe possible side
effects to you in a way you could understand?
Never
Sometimes
Usually
Always
30. After you left the hospital, did you go directly to your own home, to someone else’s home,
or to another health facility?
Own home
Someone else’s home
Another health facility if Another health facility, Go to Question 33
31. During this hospital stay, did doctors, nurses, or other hospital staff talk with you about
whether you would have the help you needed when you left the hospital?
Yes
No
32. During this hospital stay, did you get information in writing about what symptoms or health
problems to look out for after you left the hospital?
Yes
No
33. Using any number from 0 to 10, where 0 is the worse hospital possible and 10 is the best
hospital possible, what number would you use to rate this hospital during your stay?
0 – worst hospital possible
1
2
3
4
5
6
7
8
9
10 – Best hospital possible
34. Would you recommend this hospital to your friends and family?
Definitely no
Probably no
Probably yes
Definitely yes
ABOUT YOU
There are only a few questions left.
35. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
36. 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
37. Are you of Spanish, Hispanic, or Latino origin or descent?
No, not Hispanic, Latino/a, or Spanish
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/Latino
38. What is your race? Please choose one or more.
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
39 What language do you mainly speak at home?
English
Spanish
Chinese
Russian
Vietnamese
Some other language (please print): __________________________
Thank you
Please return the completed survey in the postage-paid envelope.
ER Patient Experience Survey – Admitted to Hospital (HCAHPS Add On) Version
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jeremy Mingura |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |