Form CMS-10500 Outpatient and Ambulatory Surgery OAS CAHPS Survey

Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS) Survey (CMS-10500)

OAS CAHPS_OMB_Attachment_A_OAS CAHPS Survey-04-21-15

Preparing Patient Records

OMB: 0938-1240

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Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey

(OAS CAHPS®)


A patient experience of care survey about outpatient and ambulatory surgeries and procedures




April 2015
Attachment A



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 0938-XXXX. The time required to complete this information collection is estimated to average 8 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.




Survey Instructions

Answer all the questions by checking the box to the left of your answer.

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

No If No, go to #1.

This survey asks about your experience at the facility named in the cover letter. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure.

Please answer these questions only for the procedure(s) you had on the date included in the cover letter. Do not include any other procedures in your answers.

I. Before Your Procedure

The first few questions are about getting ready for your procedure. Include any information you received before and on the day of your procedure.

  1. Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure?

  1. Shape1 Yes, definitely

  1. Shape2 Yes, somewhat

  2. Shape3 No

  1. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?

  1. Shape4 Yes, definitely

  1. Shape5 Yes, somewhat

  2. Shape6 No

II. About the Facility and Staff

The next questions ask about the day of your procedure.

  1. Did the check-in process run smoothly?

  1. Shape7 Yes, definitely

  1. Shape8 Yes, somewhat

  2. Shape9 No

  1. Was the facility clean?

  1. Shape10 Yes, definitely

  1. Shape11 Yes, somewhat

  2. Shape12 No

  1. Were the clerks and receptionists at the facility as helpful as you thought they should be?

  1. Shape13 Yes, definitely

  1. Shape14 Yes, somewhat

  2. Shape15 No

  1. Did the clerks and receptionists at the facility treat you with courtesy and respect?

  1. Shape16 Yes, definitely

  1. Shape17 Yes, somewhat

  2. Shape18 No

  1. Did the doctors and nurses treat you with courtesy and respect?

  1. Shape19 Yes, definitely

  1. Shape20 Yes, somewhat

  2. Shape21 No

  1. Did the doctors and nurses make sure you were as comfortable as possible?

  1. Shape22 Yes, definitely

  1. Shape23 Yes, somewhat

  2. Shape24 No

III. Communications About your Procedure

As a reminder, please include any information you received before and on the day of the procedure.

  1. Did the doctors and nurses explain your procedure in a way that was easy to understand?

  1. Shape25 Yes, definitely

  1. Shape26 Yes, somewhat

  2. Shape27 No

  1. Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia?

  1. Shape28 Yes

  1. Shape29 No If No, go to #13

  1. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand?

  1. Shape30 Yes, definitely

  1. Shape31 Yes, somewhat

  2. Shape32 No

  1. Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand?

  1. Shape33 Yes, definitely

  1. Shape34 Yes, somewhat

  2. Shape35 No

  1. Discharge instructions include things like symptoms you should watch for after your procedure, instructions about medicines, and home care. Before you left the facility, did you get written discharge instructions?

  1. Shape36 Yes

  1. Shape37 No



IV. Your Recovery

  1. Did your doctor or anyone from the facility prepare you for what to expect during your recovery?

  1. Shape38 Yes, definitely

  1. Shape39 Yes, somewhat

  2. Shape40 No

  1. Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure?

  1. Shape41 Yes, definitely

  1. Shape42 Yes, somewhat

  2. Shape43 No

  1. At any time after leaving the facility, did you have pain as a result of your procedure?

  1. Shape44 Yes

  1. Shape45 No

  1. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting?

  1. Shape46 Yes, definitely

  1. Shape47 Yes, somewhat

  2. Shape48 No

  1. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?

  1. Shape49 Yes

  1. Shape50 No

  1. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure?

  1. Shape51 Yes, definitely

  1. Shape52 Yes, somewhat

  2. Shape53 No

  1. At any time after leaving the facility, did you have bleeding as a result of your procedure?

  1. Shape54 Yes

  1. Shape55 No

  1. Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection?

  1. Shape56 Yes, definitely

  1. Shape57 Yes, somewhat

  2. Shape58 No

  1. At any time after leaving the facility, did you have any signs of infection?

  1. Shape59 Yes

  1. Shape60 No





V. Your Overall Experience

  1. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?

Shape61 0 Worst facility possible

Shape62 1

Shape63 2

Shape64 3

Shape65 4

Shape66 5

Shape67 6

Shape68 7

Shape69 8

Shape70 9

Shape71 10 Best facility possible

  1. Would you recommend this facility to your friends and family?

  1. Shape72 Definitely no

  1. Shape73 Probably no

  2. Shape74 Probably yes

  3. Shape75 Definitely yes

VI. About You

  1. In general, how would you rate your overall health?

  1. Shape76 Excellent

  1. Shape77 Very good

  2. Shape78 Good

  3. Shape79 Fair

  4. Shape80 Poor

  1. In general, how would you rate your overall mental or emotional health?

  1. Shape81 Excellent

  1. Shape82 Very good

  2. Shape83 Good

  3. Shape84 Fair

  4. Shape85 Poor

  1. What is your age?

  1. Shape86 18 to 24

  1. Shape87 25 to 34

  2. Shape88 35 to 44

  3. Shape89 45 to 54

  4. Shape90 55 to 64

  5. Shape91 65 to 74

  6. Shape92 75 to 79

  7. Shape93 80 to 84

  8. Shape94 85 or older

  1. Are you male or female?

  1. Shape95 Male

  1. Shape96 Female

  1. What is the highest grade or level of school that you have completed?

  1. Shape97 8th grade or less

  1. Shape98 Some high school, but did not

graduate

  1. Shape99 High school graduate or GED

  2. Shape100 Some college or 2-year degree

  3. Shape101 4-year college graduate

  4. Shape102 More than 4-year college degree

  1. Are you of Hispanic, Latino/a, or Spanish origin?

  1. Shape103 Yes, Hispanic, Latino/a, or

Spanish

  1. Shape104 No, not Hispanic, Latino/a, or

Spanish If No, go to #32

  1. Which group best describes you?

  1. Shape105 Mexican, Mexican American,

Chicano/a

  1. Shape106 Puerto Rican

  2. Shape107 Cuban

  3. Shape108 Another Hispanic, Latino/a, or

Spanish origin

  1. What is your race? You may select one or more categories.

  1. Shape109 White

  1. Shape110 Black or African American

  2. Shape111 American Indian or Alaska

Native

  1. Shape112 Asian Indian

  2. Shape113 Chinese

  3. Shape114 Filipino

  4. Shape115 Japanese

  5. Shape116 Korean

  6. Shape117 Vietnamese

  7. Shape118 Other Asian

  8. Shape119 Native Hawaiian

  9. Shape120 Guamanian or Chamorro

  10. Shape121 Samoan

  11. Shape122 Other Pacific Islander

  1. How well do you speak English?

  1. Shape123 Very well

  1. Shape124 Well

  2. Shape125 Not well

  3. Shape126 Not at all

  1. Do you speak a language other than English at home?

  1. Shape127 Yes

  1. Shape128 No If No, go to #36

  1. What is that language?

  1. Shape129 Spanish

  1. Shape130 Other Language (PLEASE

SPECIFY):

(Please print.)

  1. Did someone help you complete this survey?

  1. Shape131 Yes

  1. Shape132 No If No, go to END.

  1. How did that person help you? Check all that apply.

  1. Shape133 Read the questions to me

  1. Shape134 Wrote down the answers I gave

  2. Shape135 Answered the questions for me

  3. Shape136 Translated the questions into my

language

  1. Shape137 Helped in some other way:

(EXPLAIN):

(Please print.)

  1. Shape138 No one helped me complete this

survey

END



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleOutpatient and Ambulatory Surgery Experience of Care Survey
SubjectHome Health Care CAHPS Survey
AuthorCenters for Medicare & Medicaid Services
File Modified0000-00-00
File Created2021-01-25
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