HEALTHCARE PATIENT EXPERIENCE CHECKLIST: SATISFACTION & FEEDBACK

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--- PRE-APPOINTMENT COMMUNICATION ---
[ ] Was the scheduling process easy to navigate? (Very Easy, Easy, Neutral, Difficult, Very Difficult)
[ ] Appointment Date
[ ] Scheduled Appointment Time
[ ] Did you receive appointment reminders? (Yes, No, Not Applicable)
[ ] Reminder Method(s) (Text Message, Email, Phone Call, None)
[ ] Please describe any difficulties experienced during scheduling.

--- ARRIVAL & CHECK-IN ---
[ ] Arrival Time
[ ] Check-In Method (Front Desk, Kiosk, Online Portal)
[ ] Wait Time (Minutes)
[ ] Staff Friendliness (Excellent, Good, Fair, Poor)
[ ] Comments on Check-In Experience

--- CLINICAL ENCOUNTER ---
[ ] Did the provider introduce themselves? (Yes, No, Not Applicable)
[ ] Did the provider explain the diagnosis and treatment options clearly? (Yes, Very Clearly, Yes, Understandably, Somewhat Clearly, Not Clearly, Not Discussed)
[ ] Describe the provider's communication style (e.g., empathetic, rushed, dismissive)
[ ] Rate the provider's level of empathy (1-10, 10 being highest)
[ ] Did you feel your questions were addressed adequately? (Yes, Completely, Yes, Mostly, Somewhat, Not Fully, Not Addressed)
[ ] Please describe any concerns or uncertainties you have about your care plan.

--- FACILITY ENVIRONMENT ---
[ ] Temperature (Waiting Area)
[ ] Cleanliness of Waiting Area (Excellent, Good, Fair, Poor)
[ ] Noise Level (Quiet, Moderate, Noisy)
[ ] Describe any odors noticed
[ ] Lighting Adequacy (Excellent, Good, Fair, Poor)
[ ] Location of Hand Sanitizer Stations

--- BILLING & FINANCIAL COMMUNICATION ---
[ ] Was the billing process easy to understand? (Yes, No, Somewhat)
[ ] Estimate of total bill amount (if known)
[ ] Were payment options clearly explained? (Yes, No, Not Applicable)
[ ] Please describe any confusion or concerns about your bill.
[ ] Were financial assistance options discussed (if applicable)? (Yes, No, Not Applicable)
[ ] Date bill was received

--- POST-VISIT FOLLOW-UP ---
[ ] Next Appointment Scheduled?
[ ] Time of Follow-Up Call (if applicable)
[ ] Was the patient provided with clear discharge instructions? (Yes, No, N/A)
[ ] Was the patientâ€™s medication reconciliation complete? (Yes, No, N/A)
[ ] Additional Notes on Patient Follow-Up (e.g., specific instructions given, concerns raised)
[ ] Did the patient express any concerns during the follow-up? (Yes, No)

--- PATIENT FEEDBACK MECHANISMS ---
[ ] How would you prefer to provide feedback? (Online Survey, Phone Call, Email, Suggestion Box)
[ ] On a scale of 1-10 (1 being not at all, 10 being extremely), how satisfied were you with the feedback process?
[ ] Please describe what we could do to improve our feedback process.
[ ] Which of the following best describes your experience? (Easy to use, Timely, Respectful, Confidential)
[ ] Date of Feedback Submission

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