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Family Medicine Center Assessment Template V1
Family Medicine Center Assessment Template V1
Family Medicine Center Assessment Template V1
Family Medicine Center Assessment Template V1
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Family Medicine Center Assessment Template V1

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This template is HCAHPS standards compliant.

This template is HCAHPS standards compliant.

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  • 1. Peppertree Family Medicine Center Post-Visitation Personal Assessment ASSESMENT INSTRUCTIONS ♦ We would like to receive a feedback from you about the appointment scheduling we provide. ♦ Please, help us to improve our process by completing this assessment. ♦ All responses will be kept confidential and anonymous. ♦ We would like to meet your needs for care..Answer all the questions by checking the box c)Were the phone menu instructions easy toto the left of your answer. understand? 1.OUR PHONE SYSTEMa)Was it easy to reach a live operator on the □ Strongly disagreephone?□ Strongly disagree □ Disagree□ Disagree □ Neither agree nor disagree□ Neither agree nor disagree □ Agree□ Agree □ Strongly agree□ Strongly agree d)Was it clear when to choose scheduler or triage nurse?b)Did you wait a long time to reach a liveoperator? □ Strongly disagree□ Strongly disagree □ Disagree□ Disagree □ Neither agree nor disagree□ Neither agree nor disagree □ Agree□ Agree □ Strongly agree□ Strongly agreeApril 11 Page 1
  • 2. Peppertree Family Medicine Center 2.TELEPHONE PERSONNEL d)Did the live operator answer all of your questions? □ Strongly disagreea)Was the live operator friendly and helpful?□ Strongly disagree□ Disagree □ Disagree□ Neither agree nor disagree □ Neither agree nor disagree□ Agree □ Agree□ Strongly agree □ Strongly agree 3.EASE OF GETTING AN APPOINTMENTb) Did the live operator treat you withcourtesy and in professional manner? a)Was it easy to get an appointment?□ Strongly disagree □ Strongly disagree□ Disagree □ Disagree□ Neither agree nor disagree □ Neither agree nor disagree□ Agree □ Agree□ Strongly agree □ Strongly agreec) Did the live operator show concern and b)An appointment was available when needed?sensitivity to your needs?□ Strongly disagree □ Strongly disagree□ Disagree □ Disagree□ Neither agree nor disagree □ Neither agree nor disagree□ Agree □ Agree□ Strongly agree □ Strongly agreeApril 11 Page 2
  • 3. Peppertree Family Medicine Centerc)An appointment with desired doctor was c)Did you feel that your privacy was protected?available when needed? □ Strongly disagree□ Strongly disagree □ Disagree□ Disagree □ Neither agree nor disagree□ Neither agree nor disagree □ Agree□ Agree □ Strongly agree□ Strongly agree 4.REQUESTED INFORMATION 5. What do you like least about your schedulinga)Did the live operator verify that your insurance experience?is accepted from our office?□ Strongly disagree□ Disagree□ Neither agree nor disagree□ Agree□ Strongly agree 6. Do you have any suggestions?b)Did the live operator get your addressinformation?□ Strongly disagree□ Disagree□ Neither agree nor disagree□ Agree□ Strongly agreeApril 11 Page 3
  • 4. Peppertree Family Medicine Center 7. ABOUT YOU a) Your Age: ______ b) Your Sex: ______Male _______Female c) What language do you speak: English_____ Spanish_______ d) Are you new patient: ________Yes _______No THANK YOU FOR COMPLETING OUR SURVEY! WE VALUE YOUR OPINIION!April 11 Page 4

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