Free Patient Satisfaction Evaluation Checklist Template

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Free Patient Satisfaction Evaluation Checklist Template

Patient Satisfaction Evaluation Checklist


1. Appointment Process

Task

Completed (✓)

Ease of scheduling appointments.

Timeliness of appointment confirmation.

Availability of preferred dates and times.

Efficient check-in process upon arrival.


2. Facility Environment

Task

Completed (✓)

Cleanliness of waiting and examination areas.

Comfort and accessibility of seating and amenities.

Availability of parking or public transport options.

Clear signage and directions within the facility.


3. Staff Interaction

Task

Completed (✓)

Friendliness and professionalism of front desk staff.

Courteousness and empathy were shown by the medical staff.

Effective communication during interactions.

Respect for patient privacy and confidentiality.


4. Consultation Experience

Task

Completed (✓)

Time spent by the provider to explain the diagnosis and treatment.

Provider’s ability to answer patient questions thoroughly.

Perception of provider’s knowledge and expertise.

Clear communication of follow-up care instructions.


5. Treatment and Outcomes

Task

Completed (✓)

Satisfaction with the effectiveness of the treatment.

Minimal waiting times for procedures or treatments.

Adequate pain management or comfort measures.

Accessibility of prescribed medications or resources.


6. Feedback and Follow-Up

Task

Completed (✓)

Opportunity to provide feedback on the experience.

Timeliness and effectiveness of follow-up appointments.

Resolution of concerns or issues raised by the patient.

Overall satisfaction with the care received.


Overall Patient Satisfaction Rating:

  • Excellent

  • Satisfactory

  • Needs Improvement

  • Poor


Additional Comments:
[Insert any additional feedback, observations, or suggestions for improvement.]


Evaluator Name: [Your Name]
[Date Signed]

Patient Name: [Patient Name]
[Date Signed]


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