About this template
Gather actionable patient feedback regarding emergency department visits with this comprehensive satisfaction survey. Designed for hospitals and urgent care centers, this form allows patients or their family members to evaluate key aspects of their visit, including nursing care, physician explanations, admission efficiency, facility cleanliness, and overall wait times.
Collecting structured feedback after an emergency room visit is essential for identifying operational bottlenecks, improving bedside manner, and maintaining high standards of patient care. Healthcare administrators and quality assurance teams can use the responses to track performance trends and implement targeted improvements. With Doc2Form, you can deploy this assessment instantly as a Google Form, making it easy to analyze results directly within Google Sheets.
Key features
- Evaluate nursing and physician care quality systematically
- Measure patient perceptions of wait times and admission processes
- Assess facility cleanliness and emergency room environment
- Capture open-ended comments for specific service improvements
- Export and analyze results instantly using Google Sheets
Use cases
Post-visit patient experience tracking for hospital emergency departm…
Post-visit patient experience tracking for hospital emergency departments
Quality assurance reviews for urgent care clinic management
Internal audits of nursing and physician communication standards
What this form collects
- Full Name (Short answer)Enter your first and last name, or leave blank if you prefer to remain anonymous.
- Phone Number (Short answer)Optional contact number in case our patient relations team needs to follow up.
- Email Address (Short answer)Where can we reach you if necessary?
- Emergency Department Visit Date (Date)Select the date you received care in the emergency department.
- Diagnosis or Reason for Visit (Short answer)Briefly describe the primary reason for your emergency room visit.
- Nurses prioritized my treatment (Linear scale)Indicate your level of agreement with this statement.
- Nurses explained treatment process (Linear scale)Did the nursing staff clearly explain procedures and next steps?
- Nurses were patient during care (Linear scale)How patient and attentive were the nurses?
- Nurses tried to stop my pain (Linear scale)Assess how effectively your pain management needs were addressed.
- Admission staff were informative (Linear scale)Were check-in procedures and paperwork clearly explained?
- Admission staff treated me kindly (Linear scale)Assess the courtesy and professionalism of the front desk team.
- Emergency room was tidy and quiet (Linear scale)How satisfied were you with the ambient environment of the ER?
- Emergency room hygiene satisfaction (Linear scale)Rate the cleanliness of the waiting areas and exam rooms.
- Physician explained treatment process (Linear scale)Did the doctor clearly explain your diagnosis and care plan?
- Physician treated me kindly (Linear scale)Assess the bedside manner and empathy of the doctor.
- Understood physician explanations (Linear scale)Were medical terms explained in a way that was easy to understand?
- Physician exam time was sufficient (Linear scale)Did you feel the doctor spent enough time addressing your concerns?
- Wait time before physician exam (Linear scale)Rate your satisfaction with how long you waited to see a doctor.
- Wait time for admission process (Linear scale)Rate your satisfaction with the speed of the admission or registration process.
- Family treated kindly by staff (Linear scale)If family members accompanied you, how well were they treated?
- Family visitation time was adequate (Multiple choice)Were visitation policies accommodating during your stay?
- Satisfied with emergency services (Linear scale)Overall, how satisfied are you with the emergency services you received?
- Would recommend emergency department (Linear scale)How likely are you to recommend our emergency department to friends or family?
- Additional Comments or Suggestions (Paragraph)Please share any further feedback, compliments, or suggestions for how we can improve.
FAQ
How can I share this survey with patients?
Once converted to a Google Form, you can share it via a direct link, QR code displayed in discharge areas, or via email follow-up.
Can I customize the questions to fit our specific hospital department?
Yes, you can easily add, remove, or edit any questions directly in your Google Form builder after generation.
Where are survey responses stored?
All patient responses are securely saved in your Google Drive and automatically populated into a linked Google Sheet for real-time analysis.
Is this template free to use?
Yes, Doc2Form provides this template free of charge so you can convert and launch your Google Form in seconds.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.