Form CMS-10500 OAS CAHPS (Mail Survey)

OMB No. 0938-1240
Expires 12/31/2021

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

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 0938-1240 WITH AN EXPIRATION DATE OF DECEMBER 31,

2021. 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,

05, BALTIMORE, M ARYLAND 21244-1850.

ATTN: PRA REPORTS CLEARANCE OFFICER, MAIL STOP C4-26-

SURVEY INSTRUCTIONS

2.

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:

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.

3.

4.

I. BEFORE YOUR PROCEDURE

5.

The first few questions are about getting
ready for your procedure. Include any
information you received before and
on the day of your procedure.
Before your procedure, did your
doctor or anyone from the facility
give you all the information you
needed about your procedure?
Yes, definitely

2

Yes, somewhat

3

No

Yes, definitely

2

Yes, somewhat

3

No

The next questions ask about the day of
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.

1

1

II. ABOUT THE FACILITY AND STAFF

Yes

1.

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

6.

1

Did the check-in process run
smoothly?
1

Yes, definitely

2

Yes, somewhat

3

No

Was the facility clean?
1

Yes, definitely

2

Yes, somewhat

3

No

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

Yes, definitely

2

Yes, somewhat

3

No

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

Yes, definitely

2

Yes, somewhat

3

No

7.

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

8.

1

Yes, definitely

2

Yes, somewhat

3

No

11.

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

12.

Yes, definitely

2

Yes, somewhat

3

No

1

Yes, definitely

2

Yes, somewhat

3

No

1

Yes, definitely

2

Yes, somewhat

3

No

13.

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

10.

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?

III. COMMUNICATIONS ABOUT YOUR
PROCEDURE

9.

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

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

Yes, definitely

2

Yes, somewhat

3

No

2

14.

Yes
No

1

Yes

2

No

IV. YOUR RECOVERY

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

If No, go to #13

2

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

Yes, definitely

2

Yes, somewhat

3

No

19.

The next questions are about possible
outcomes you could have during
recovery. Some procedures do not
require that you get this information.
Please answer based on what you
remember.
15.

16.

17.

18.

Some ways to control pain include
prescription medicine, over-thecounter 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

Yes

2

No

20.

21.

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

Yes

2

No

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

Yes

2

No

22.

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

Yes

2

No

3

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

Yes

2

No

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

Yes

2

No

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

Yes

2

No

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

Yes

2

No

V. YOUR OVERALL EXPERIENCE
23.

26.

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?
0 Worst facility possible
1
2
3
4
5
6
7
8
9
10 Best facility possible

24.

27.

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

Definitely no

2

Probably no

3

Probably yes

4

Definitely yes

28.

VI. ABOUT YOU
25.

29.

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

Excellent

2

Very good

3

Good

4

Fair

5

Poor

4

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

Excellent

2

Very good

3

Good

4

Fair

5

Poor

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

8th grade or less

2

Some high school, but did not
graduate

3

High school graduate or GED

4

Some college or 2-year degree

5

4-year college graduate

6

More than 4-year college
degree

Are you of Hispanic, Latino, or
Spanish origin?
1

Yes, Hispanic, Latino, or
Spanish

2

No, not Hispanic, Latino, or
Spanish If No, go to #30

Which group best describes you?
1

Mexican, Mexican American,
Chicano

2

Puerto Rican

3

Cuban

4

Another Hispanic, Latino, or
Spanish origin

30.

31.

32.

33.

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

Did someone help you complete
this survey?

1

White

1

Yes

2

Black or African American

2

No

3

American Indian or Alaska
Native

4

Asian Indian

5

Chinese

6

Filipino

7

34.

If No, go to END.

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

Read the questions to me

2

Japanese

Wrote down the answers I
gave

3

8

Korean

Answered the questions for me

4

9

Vietnamese

Translated the questions into
my language

10

Other Asian

5

11

Native Hawaiian

12

Guamanian or Chamorro

13

Samoan

Helped in some other way:
(EXPLAIN):
________________________
(Please print.)

6

14

Other Pacific Islander

No one helped me complete
this survey

How well do you speak English?
1

Very well

2

Well

3

Not well

4

Not at all

END

What language do you mainly
speak at home?
1

English

2

Spanish

3

Chinese

4

Russian

5

Vietnamese

6

Portuguese

7

German

9

Some other language

5