QAPI Program Utilization_Manual

QUALITY ASSURANCE (QAPI) EVALUATION FORM PATIENT / FAMILY QUESTIONNAIRE DATE OF EVALUATION: NAME OF STAFF RECORDING THE EVALUATION: _______________________________ NAME OF PATIENT: NAME OF PERSON MAKING RESPONSES: (person being interviewed) Rating from 1 “Disagree” - 5 “Strongly Agree” QUESTIONS ALWAYS/Good 4 - 5 SOMETIMES 2 - 3 NEVER 1 1. Did you like your nurse/aide/therapist? 2. Was your nurse/aide/therapist always there when she was expected to be there? 3. Did your nurse/aide/therapist always wear a clean uniform? 4. Did your nurse/aide/therapist appear to know her job? 5. Was your nurse/aide/therapist punctual? 6. Would you say the nurse/aide/therapist took good care of you? 7. Was your nurse/aide/therapist a good listener? 8 . Perception of effectiveness of Care Provided: Care Plan Management, Disease Management, Pain Management, Patient’s Safety, Medication Management, Infection Prevention, Fall prevention . 9. Your nurse/aide/therapist were always available to communicate with you? Other Comments ________________________________ __________________________________ Signature of Staff Patient’s Signature (optional) 14