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Survey Instructions

Think about the way things are done in your medical office and provide your opinions on issues that affect the overall safety and quality of the care provided to patients in your office.

►In this survey, the term provider refers to physicians, physician assistants, and nurse practitioners who diagnose, treat patients, and prescribe medications. The term staff refers to all others who work in the office.

If a question does not apply to you or you don’t know the answer, please check “Does Not Apply or Don’t Know.”

If you work in more than one office or location for your practice, when answering this survey answer only about the office location where you received this survey—do not answer about the entire practice.

If your medical office is in a building with other medical offices, answer only about the specific medical office where you work—do not answer about any other medical offices in the building.

SECTION A: List of Patient Safety and Quality Issues

The following items describe things that can happen in medical offices that affect patient safety and quality of care. In your best estimate, how often did the following things happen in your medical office OVER THE PAST 12 MONTHS?

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* 1. Access to Care: A patient was unable to get an appointment within 48 hours for an acute/serious problem

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* 2. Patient Identification: The wrong chart/medical record was used for a patient

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* 3. Charts/Medical Records: A patient’s chart/medical record was not available when needed............

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* 4. Charts/Medical Records: Medical information was filed, scanned, or entered into the wrong patient’s chart/medical record

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* 5. Medical Equipment: Medical equipment was not working properly or was in need of repair or replacement.

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* 6. Medication: A pharmacy contacted our office to clarify or correct a prescription

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* 7. Medication: A patient's medication list was not updated during his or her visit. 

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* 8. Diagnostics & Tests: The results from a lab or imaging test were not available when needed. 

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* 9. Diagnostics & Tests: A critical abnormal result from a lab or imaging test was not followed up within 1 business day. 

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