FORT WASHAKIE MEDICAL HOME PATIENT FEEDBACK
|
Form Approved OMB No. 0917 - Exp. Date XX/XX/20XX |
We are continually trying to improve the quality of services at Fort Washakie Medical Home.
By taking a few minutes to answer these questions about the care you have received, you can help us improve the services we provide.
DID YOU HAVE AN APPOINTMENT? YES NO
A
EXCELLENT B
GOOD C
AVERAGE D
POOR F
FAILING
GRADE THOSE SERVICES RECEIVED (CIRCLE ONE)
NA- not applicable or did not use service
Doctor Care A B C D F - NA
Nursing Care A B C D F - NA
Patient Registration A B C D F - NA
Pharmacy A B C D F - NA
Dental A B C D F - NA
Behavioral Health A B C D F - NA
Purchased Referred Care A B C D F - NA
Optometry A B C D F - NA
Lab A B C D F - NA
X-ray A B C D F - NA
Public Health Nurse A B C D F - NA
Diabetes Educator A B C D F - NA
Electronic Health A B C D F - NA
Record
GIVE US A GRADE FOR THE FOLLOWING:
Staff courtesy A B C D F - NA
Answering your questions A B C D F - NA
Understanding the doctor’s instructions
A B C D F - NA
Staff teaching you about your medical problem
A B C D F - NA
Teaching you about your medicines
A B C D F - NA
Telephone accessibility to the clinic
A B C D F - NA
Convenience of getting an appointment
A B C D F - NA
How long you had to wait to see the doctor
A B C D F - NA
Cleanliness of the clinic A B C D F - NA
Ventilation & temperature of the clinic
A B C D F - NA
Satisfaction with the referral services outside of the clinic A B C D F - NA
Confidentiality / privacy of medical information
A B C D F - NA
Ease of contacting the after hour services
at night/weekends? A B C D F - NA
Overall care A B C D F - NA
Satisfaction with diabetes-related services
A B C D F - NA
Do you know how to access your personal health record (PHR) on the internet?
YES or No (circle one)
(If interested contact our patient registration staff)
If clinic hours were expanded what times would you more likely use services? We are currently open 8:00am to 5:30pm each weekday
Weekday evenings
Saturdays
Sundays
Both evenings and weekend days
No need to change current hours
Are there services that you think are especially good or especially poor? Why?
Good services:
Poor services:
In what way(s) would you most like to improve the clinic? (use back of page for additional comments)
*THANK YOU*
for taking the time to help us improve services.
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 0917-00xx. 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, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Services, DRA, 5600 Fishers Lane, Rockville, MD 20852, Attention: PRA/Information Collections Clearance Officer.
| File Type | application/msword |
| File Title | SOUTHERN UTE HEALTH CENTER |
| Author | Schiffel / Jordan |
| Last Modified By | SYSTEM |
| File Modified | 2017-11-21 |
| File Created | 2017-11-21 |