MICs Group of Health Services

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* 1. Discharge Date

Date

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* 2. I am being discharged from

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* 3. My nurses listened carefully to me

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* 4. My nurses treated me with courtesy and respect

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* 5. My nurses explained things in a way I could understand

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* 6. When I pressed the call button, I got help when I needed it

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* 7. My doctors listened carefully to me

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* 8. My doctors treated me with courtesy and respect

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* 9. My doctors explained things in a way I could understand

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* 10. My room was kept clean

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* 11. My bathroom was kept clean

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* 12. My room and area were quiet at night

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* 13. My food and beverage serviced at an acceptable temperature

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* 14. I received the service/assistance required in order to meet my needs at meal time.

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* 15. I received an X-ray and/or Ultrasound (Diagnostic Imaging) during my stay in hospital and it was a good experience.

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* 16. My pain was well controlled

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* 17. Staff did everything they could to keep me comfortable

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* 18. I was told about new medication prescribed for me

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* 19. I was told what side effects to expect after starting new medication

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* 20. I was given a clear and complete explanation by the staff prior to any procedure or exam

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* 21. The hospital staff consulted me or my family or caregiver in making decisions about my care

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* 22. The quality of care or services provided by the staff was

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* 23. When I leave the hospital, I am going to

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* 24. The help that I need to care for myself at home has been arranged

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* 25. Written information, about what to look out for after I leave the hospital, was provided to me

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* 26. I understand what I am responsible for to manage my health

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* 27. Overall, my experience was

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* 28. I would recommend this hospital to friends and family

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* 29. I was offered services, during my care, in my preferred language. (Check preferred language)

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* 30. My experience would have been better if

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* 31. I would you like to recognize someone special on your staff who helped make my experience excellent