Hospital Feedback Form

Feedback Form

Dear Patient / Relative / Visitor,

Your continuing suggestions & support help to make our Hospital a better organization. Kindly spare a few moments to complete the following, so that we can strive to fulfill your expectations. Please drop the completed Feedback Form in the collection box, placed at the OPD reception, or hand it over personally to Administrator – OPD / MS.

Warm Regards,

Director’s Office

FEEDBACK FORM

I came as a (Please Tick)          Patient                         Relative                        Visitor

NAME                                                 REG. NO.        AGE                            SEX M / F

ADDRESS                  

PHONE / EMAIL                                                                               DOCTOR

DIAGNOSIS                                                   TREATMENT

My hospital stay at VJEH was because of the following factors :

           Pleasant           Satisfactory    Unpleasant 

The Hospital environment is                                                    Good                Average           Poor 

The Toilet(s) are                                                                        Good                Average           Poor 

The service of attending Doctors is                                          Good                Average           Poor 

The service of attendant Nurses is                                            Good                Average           Poor 

The Hospital Billing is                                                               Good                Average           Poor 

The Reception / Enquiry service is                                           Good                Average           Poor 

The Admission Process is                                                          Good                Average           Poor 

The Discharge Process is                                                          Good                Average            Poor 

Were you satisfied with the care & procedure                          Good                Average            Poor 

Overall I rate VJEH as                                                              Good                Average            Poor

Would you prefer to recommend us to others?       Strongly     Most likely   Less likely    Never

Special Comments:

Thanks for giving your valuable time to fill up this form. We are committed in providing you with the best quality care possible.

NEW PATIENT REGISTRATION FORM

NEW PATIENT REGISTRATION FORM

MR No.                                                                                                                                  Date

If the patient has a ____________________ card number (taken in OPD/Health Check up/Casualty/Admission) please DO NOT fill this form,

kindly inform the counter staff to find your MR number.

Patient Name                                                                                       Father/ Husband Name

Age                         Sex                         Date of Birth                        Mobile

Residential Address

Consultant Name

Referring Doctor Name

I understand that my medical record will be destroyed 3 years after my last visit to this hospital.

Patient Name                                                       Signature

GENERAL CONSENT

1. I/ We agree for the patient to undergo examination, investigations and treatment as decided by the hospital and also to abide by its schedule of charges, rules and regulations (available at registration counter).

2. I authorize Mr./Ms.                                                                               to take decision on my behalf in case of my inability to do so due to associated medical condition.

3. I understand that I have to disclose my clinical history and other relevant information to the healthcare provider team required for the management of my disease.

4. I am fully aware that the medical treatment may be extended beyond the expected period at the discretion of the doctor.

5. If my financial credit status is disputed by credit/insurance company/TPA, I undertake to settle the final bill on the date of discharge. I also undertake to make payment against interim bills raised within stipulated time.

6. The doctor’s discretion shall be considered as final for my discharge. I assent for transfer out from your hospital to other hospital/ nursing home in case of non-payment of bill/ discretion of doctor.

7. I certify that I read the above and understand the contents. I further state that I have been given an opportunity to ask questions and all my questions have been answered fully and to my satisfaction.

Patient/ Relative Name                                                                                      Relationship

Signature                                                                                                               Date

FACILITY INSPECTION CHECKLIST

FACILITY INSPECTION CHECKLIST

Inspector:

Date:

This inspection checklist monitors the compliance activities at the facility.  It also serves as a hazard assessment to current activities.  The inspection shall be completed in all areas of the facility, including warehouse and office areas as it is applicable.  Issues shall be summarized on the last page.  Corrections will be made and documented completion date on the summary page.   All corrections are expected to be completed in a timely manner.

EMERGENCY EXIT	Yes	No	N/A	Comments
All exit signs well placed and visible easily at all time?
All exit signs free of damage?

                                                                                                       

EMERGENCY PREPAREDNESS	Yes	No	N/A	Comments
Are all aisle ways free of obstructions?
Are all exits free of storage and clutter?
Are stairwells and corridors free of storage and clutter?
Are all employees trained on Emergency Evacuation Procedures?
Are all employees aware of the proper meeting location in the event of an emergency?
Is the fire alarm is working condition?
Is there anything else relating to emergency preparedness that needs attention at this time?

FIRE EXTINGUISHERS	Yes	No	N/A	Comments
Are all extinguishers in their designated location?
Are all extinguishers clearly identified with a wall mounted sign?
Are all extinguishers securely mounted to the wall?
Are all extinguishers easily accessible and free of obstructions?
Is the last annual inspection within the past 12 months?
Are inspection tags current with initial and date of inspection?
Are all seals and tamper pins in place?
Are all extinguishers free of damage, corrosion, leakage or clogged nozzles?
Do all pressure gauges indicate the extinguishers are ready for use?
Are all staff members trained on fire extinguisher use?
Is there anything else that needs attention at this time?

HAZARDOUS MATERIALS	Yes	No	N/A	Comments
Are MSDS available on all hazardous materials in the facility?
Are all MSDS readily available for all employees?
Are all employees trained on how to locate, read and understand an MSDS sheet? (Hazard Communications)
Are all personnel equipped with adequate PPE for these materials?
Are all spill kits located in the correct area?
Are all spill kits fully stocked with the needed equipment?
Is there anything else relating to hazardous materials that needs attention at this time?

HOUSEKEEPING	Yes	No	N/A	Comments
Are all areas cleaned on a regular basis?
Are all walkways are free of other items that could cause a tripping hazard?
Are all floors free of liquids to avoid trips and falls?
Is housekeeping staff having and using PPE?
Are housekeeping items properly atored and easily available to the staff?
Flammable materials such as cardboard and paper are stored away from fire hazards.
Are there any other housekeeping issues that need to be addressed?

ELECTRICAL	Yes	No	N/A	Comments
No circuit breakers regularly tripping?
No extension cords used for a permanent operation?
Are all plugs and cords in good condition?
No electrical switches, switch plates or receptacles, cracked, broken or have exposed contacts?
Are all electrical circuit breakers identified?
Are there any other electrical issues that need attention at this time?

PERSONAL PROTECTIVE EQUIPMENT	Yes	No	N/A	Comments
Is there adequate PPE for all job types on site?
Are all personnel trained in the proper use of all PPE as required by their job(s)?
Is signage displayed in areas where PPE is required?
Are employees wearing proper footwear in accordance with PPE requirements?
Are employees wearing gloves wear required by the tasks?
Are there any other PPE issues that need to be addressed at this time?

SECURITY	Yes	No	N/A	Comments
Are all entry ways secured from unauthorized access?
Are surveillance video cameras in working order?
Are video recording devices in working order and storing video accordingly?
Are there any other security issues to be addressed?

Other Equipment Maintenance	Working	Broken	N/A	Comments
Fans
Tables
Lighting
Carts
Dust Bins
Computer Equipment
Patients Beds
Stretchers
Wheel Chairs
RO Water

Air Compressor	Yes	No	N/A	Comments
Was the air compressor drained of fluid?
Is the pressure gauge in working order?
Is the operating pressure within manufacturer’s specifications?
Is the safety valve in working order?
Are there any leaks in the lines?
Is complaint register daily checked?

Date of Review:

Mgmt. Reviewer:

	Unsafe condition or work practice	Person Assigned	Corrective Actions	Due Date	Resolution Date
1
2
3
4
5
6
7

                                                                                                                                SIGNATURE

                                                                                                            MEDICAL SUPERINTENDENT