Form CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials

Draft Hospital Experience Survey

Survey content subject to pending rulemaking August 2024
SURVEY INSTRUCTIONS
♦ This survey asks about you and the care you received during the hospital stay named in
the cover letter.
♦ 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 Question 1

You may notice a number on the survey. This number is used to let us know if you
returned your survey so we don't have to send you reminders. Please note:
Questions 1-32 in this survey are part of a national initiative to measure the quality
of care in hospitals. OMB #0938-0981 (Expires TBD)
Please answer the questions in this
survey about your stay at the hospital
named on the cover letter. Do not include
any other hospital stays in your answers.

3.






YOUR CARE FROM NURSES
1.

During this hospital stay, how often
did nurses treat you with courtesy
and respect?





2.

Never
Sometimes
Usually
Always

During this hospital stay, how often
did nurses listen carefully to you?






Never
Sometimes
Usually
Always

Draft May 2024

During this hospital stay, how often
did nurses explain things in a way
you could understand?
Never
Sometimes
Usually
Always

YOUR CARE FROM DOCTORS
4.

During this hospital stay, how often
did doctors treat you with courtesy
and respect?






Never
Sometimes
Usually
Always

1

5.

During this hospital stay, how often
did doctors listen carefully to you?





6.

Never
Sometimes
Usually
Always

During this hospital stay, how often
did doctors explain things in a way
you could understand?






Never
Sometimes
Usually
Always

THE HOSPITAL ENVIRONMENT
7.

During this hospital stay, how often
were your room and bathroom kept
clean?





8.

During this hospital stay, how often
were you able to get the rest you
needed?





9.

Never
Sometimes
Usually
Always

During this hospital stay, how often
was the area around your room
quiet at night?





2

Never
Sometimes
Usually
Always

YOUR CARE IN THIS HOSPITAL
10. During this hospital stay, how often
were doctors, nurses and other
hospital staff informed and up-todate about your care?

 Never
 Sometimes
 Usually
 Always
11. During this hospital stay, how often
did doctors, nurses and other
hospital staff work well together to
care for you?

 Never
 Sometimes
 Usually
 Always
12. During this hospital stay, did you
need help from nurses or other
hospital staff in getting to the
bathroom or in using a bedpan?

 Yes
 No  If No, Go to Question 14

1

2

13. 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

Never
Sometimes
Usually
Always

Draft May 2024

14. During this hospital stay, when you
asked for help right away, how often
did you get help as soon as you
needed?

 Never
 Sometimes
 Usually
 Always
 I never asked for help right away
15. During this hospital stay, were you
given any medicine that you had not
taken before?




Yes
No  If No, Go to Question 18

16. Before giving you any new
medicine, how often did hospital
staff tell you what the medicine was
for?






Never
Sometimes
Usually
Always

17. Before giving you any new
medicine, how often did hospital
staff describe possible side effects
in a way you could understand?






Never
Sometimes
Usually
Always

18. During this hospital stay, did
doctors, nurses and other hospital
staff help you to rest and recover?

 Yes, definitely
 Yes, somewhat
 No

Draft May 2024

LEAVING THE HOSPITAL

19. Did doctors, nurses or other
hospital staff work with you and
your family or caregiver in making
plans for your care after you left the
hospital?

 Yes, definitely
 Yes, somewhat
 No
20. Did doctors, nurses or other
hospital staff give your family or
caregiver enough information about
what symptoms or health problems
to watch for after you left the
hospital?

 Yes, definitely
 Yes, somewhat
 No
 I did not have family or a caregiver
watch for symptoms or health
problems

21. When 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, Go to
Question 24

22. During this hospital stay, did
doctors, nurses or other hospital
staff talk with you about whether
you would have the help you needed
after you left the hospital?




Yes
No

3

23. 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

OVERALL RATING OF HOSPITAL
Please answer the following questions
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.
24. Using any number from 0 to 10,
where 0 is the worst 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

25. Would you recommend this hospital
to your friends and family?
 Definitely no
 Probably no
 Probably yes
 Definitely yes

4

ABOUT YOU
There are only a few remaining items left.
26. Was this hospital stay planned in
advance?





Yes, definitely
Yes, somewhat
No

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







Excellent
Very good
Good
Fair
Poor

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







Excellent
Very good
Good
Fair
Poor

29. What language do you mainly speak
at home?






English
Spanish
Chinese
Another language

Draft May 2024

30. 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

31. Are you of Spanish, Hispanic or
Latino origin?





32. What is your race? Please choose
one or more.

No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Mexican, Mexican American,
Chicano
Yes, Puerto Rican
Yes, other Spanish/Hispanic/Latino



American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
White

NOTE: IF HOSPITAL-SPECIFIC
SUPPLEMENTAL QUESTION(S) ARE
ADDED, THE MANDATORY TRANSITION
STATEMENT MUST BE PLACED
IMMEDIATELY BEFORE THE
SUPPLEMENTAL QUESTION(S).

THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]
[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Questions 1-32 in this survey are works of the U.S. Government and are in the public domain and therefore are
NOT subject to U.S. copyright laws.

Draft May 2024

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