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Post Admission Survey

FILL UP FORM

Please fill out our post-admission survey. Thank you for participating in the improvement of our services:

1. After you were notified that you were to receive a call from the Agency in a
timely manner to set up your Initial visit?

Yes    No

2. Did your admitting professional give you the telephone number and contact person
at the agency in case you had any questions or concerns, including after hours information?

Yes    No

3. Did you participate in your plan of care?

Yes    No

4. Did you receive information on your Bill of Rights including the State Hotline
number to call if you have any complaints?

Yes    No

5. Did the agency admitting nurse present a professional appearance?

Yes    No

6. Did the nurse wear a name tag and introduce himself/herself as a
representative of the agency and explain his/her role?

Yes    No

7. Did the nurse leave a folder with information about your care in your home?

Yes    No

8. Do you understand the services that your doctor ordered?

Yes    No

9. Did the staff tell you the date of your next visit and the frequency of visits?

Yes    No

10. Did the nurse take your temperature, pulse, respirations and blood pressure?

Yes    No

11. Did the nurse wash her hands before and after caring for you?

Yes    No

12. Did the nurse teach you about:

Your medications?

Yes    No

Signs and Symptoms to report to the doctor?

Yes    No

Your diet?

Yes    No

Wound Care (if applicable)?

Yes    No

Plans for discharge (if applicable)?

Yes    No

13. Did you feel the nurse answered your questions appropriately?

Yes    No

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