The enaenation of the outcome or impact of QMs can be internal or external.
Patient Name – ___________________ Registration No. – _________________
Age – ____ Sex – M/F Room No. – _________ DOA – ___________
| Your opinion about the following | Very good | good | satisfactory | poor |
| Reception | ||||
| OPD | ||||
| Admission procedure | ||||
| Medical care | ||||
| nursing care | ||||
| Dieting service | ||||
| Housekeeping | ||||
| Physical facility | ||||
| Discharging process/billing | ||||
| Behaviour of staff/ canteen |
Patient name – _______________ Age – ________ Sex – _______
Registration No. – ____________ OPD No. – _____ Date – ________
Speciality visited – _________________________________ Room No. – _____
| Your opinion about the following | Very good | Good | Satisfactory | Poor |
| Reception | ||||
| Time taken for registration | ||||
| Waiting time for consultation | ||||
| Facilities in waiting room | ||||
| Pathology lab | ||||
| X-Ray department | ||||
| Physiotherapy | ||||
| Pharmacy | ||||
| Behaviour of the staffs | ||||
| Patients guidance system |
Any suggestion for improvement – _______________________________________
Was this your first visit to hospital? ______________________________________
Would you recommend this hospital to others? ____________________________