Form 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chi

Form Approved
OMB Form No. 0917-0036
Expiration Date:

Pediatric Care Unit (PCU) Patient Experience Survey
Male: _____

Female: _____

Patient’s Age: ______

Please rate the following statements using numbers
1-5 based on this scale.

1.
2.

I am sure I (parent/caregiver) can take care of my
child’s health.

4.

PAIN: Overall, I (parent/caregiver) was pleased with
how my child’s pain was treated.
SAFETY: I felt my child was safe during his or her
stay at Chinle Hospital.

6.

POLITENESS: The staff was polite and treated my
child and my family with respect.

7.

ENVIRONMENT: My child’s room was regularly
kept clean and organized.
LISTENING TO PATIENT/FAMILY
CONCERNS: The staff listened when I
(parent/caregiver) talked with them about my child.

8.

2
Disagree

3
Unsure

4
Agree

5
Strongly
Agree

N/A

I (parent/caregiver) would recommend the Pediatric
Care Unit (PCU) to my family and friends.
Usually, my child’s health is good.

3.

5.

1
Strongly
Disagree

Date of Discharge: ___________________

9.

ANSWERING THE CALL LIGHT: When I
(parent/caregiver) put on the call light, the nurses
answered it quickly. 1-2 minutes, 3-5 minutes, or 6
minutes or greater.
10. EXPLANATION OF TESTS & PROCEDURES:
The nurses/doctors explained tests and procedures
before they were done.
11. PATIENT RIGHTS: The staff gave me
(parent/caregiver) and my family information about
my rights as the patient’s (parent/caregiver).
12. CARE AFTER HOSPITALIZATION: The nurses
and doctors explained what I (parent/caregiver) have
to do to care for myself/child at home and when he or
she has an appointment.
13. EDUCATION AND TEACHING: While in the
hospital, the nurses and doctors explained
medications, illness, treatments, place of care, and
discharge plans.
14. OVERALL ATTITUDE TOWARDS NURSING
CARE: While in the hospital, I (parent/caregiver)
was pleased with the care my child received from the
nurses.
15. MEDICATION: The staff informed me
(parent/caregiver) or my family of the benefits and
risks of the medication my child is taking.

NO PAIN

16. ENVIRONMENT: The noise level on the PCU was
appropriate.
17. CULTURAL/TRADITIONAL VALUES: I
(parent/caregiver) felt that the PCU staff respected
my cultural values & beliefs.
18. PATIENT EDENTIFICATION: The nurse used at
least two (2) different way of identifying my child,
whenever medication or treatment was provided.
19. Using a number from 0-10, where 0 is the worst possible and 10 is the best possible, what number would you (parent/caregiver) choose to
rate all your health care during your hospital stay? (circle one)
1
2
3
4
5
6
7
8
9 10
What did we do well? _________________________________________________________________________________________
___________________________________________________________________________________________________________
What can we do better? ________________________________________________________________________________________
___________________________________________________________________________________________________________

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