QAPI Program Utilization_Manual

QUALITY ASSURANCE FORM PHYSICIAN QUESTIONNAIRE Dear Dr. We are conducting a survey on our Quality Assurance Standard. Please check the appropriate box in the questionnaire form below: Thanks. ITEMS PHYSICIAN RESPONSE EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE 1. Did agency staff display adequate knowledge and professionalism in maintaining patient records? 2. Did agency staff make themselves accessible to physician when applicable? 3. Were agency staff members able to communicate adequately with patient's family and to the physician? 4. How would you rate overall quality of nursing care toward patients as performed by the staff of this agency? 5. Other Date: Physician's signature: 18