Patient`s Evaluation of Nursing Care Received

Name: Ward /Room

No.:

Dear Client,

The Hospital is making a study on the kind of service it

provides to its clients. Our aim is to improve our services to best
serve, our clients.

It is in this light that we request you take a little time to

answer this questionnaire to meet the objective we have set. We
would like to assure that the data we will gather will not be used
against any of the respondents, will be treated with utmost
confidentiality, and will only be used for the purpose we have
stated.

We thank you for your kind cooperation on the matter.

The
Hospital Management

Directions:

Based on the services provided you, please indicate the

extent to which of the following services/activities/ goal were
accomplished.

Please use the following scores;

3 – if this is done very completely by the nurse

2 – if this is done most of the time

1 – if it is done occasionally only

0 – if it is never done.
I Assessment
1. In taking your health history :

_____a. The nurse introduces his/her name to you and to

your family member ,if present.

_____b. You and your family were oriented to your

immediate surroundings in this hospital.

_____c. You and your family were introduced to the

members of the health team.

_____d. The interview was conducted in privacy and with

utmost courtesy.

2.The health history included the following aspects.

_____a. Past illness: From childhood to adulthood

_____b. Present illness: onset, precipitating factors

_____c. Family history including risk factors such as cancers,

asthma, diabetes, hypertension, heart disease

_____d. Concern regarding hospitalization such as financial

problems, fear o hospitalization, possible outcomes of
examinations, death.

_____e. Spiritual concern: contact with spiritual adviser,

prayer groups

_____f. Medications taken / still being taken whether self-

prescribed or prescribed by the physician.
 _____g. Nutrition: idiosyncrasies, allergies, religious
restrictions

_____h. Sleep habits: how many hours a night ; interrupted

or continuous.

_____3. Coordinated examinations to be done by other

departments/ services without unnecessary delay.

_____4. Communicated result of diagnostic examination s to

health team member concerned.

_____5. Informed you and our family about the result of the
examinations which will become part of treatment.

_____6. Confirmed with you the accuracy of the data they

gathered during assessment.

II. Plan of Care

To what extent were you and your family

involved in planning of care? Use the same scores.

_____1. Shared decision making was made you and your

family in the treatment you will

receive.

_____2. Explain possible treatment, possible operations

if indicated, diagnostic examinations needed.

_____3.Explain how may call for assistance if needed.

(Call light, buzzer if any)
 _____4.Medication you will be taking, their indications,
possible side effects, precaution to take, allergies

_____5.Acivities that ma be undertaken, avoided.

_____ 6. Food to be taken considering preferences,

allergies religious and medical restrictions.

_____7.Rules and regulations and policies of the hospital

affecting your care are explained

_____ 8 . Possible expenses that may be incurred.

_____9. Meeting your spiritual needs such as priest minister,

prayer groups.

_____10. Developed a Pre-discharge Plan for you.

_____11. Community agencies/ resources that may be

approached for additional assistance.

II. Implementation of Care

______1. Explain the purpose of each procedure, treatment,
diagnostic examination at the level which can easily be
understood

_______2. Implemented / modified plans of care according to

your ability (strength , knowledge, will) to perform such

______3. Perform nursing care safety, unhurriedly, and with

utmost gentleness.

______4. Showed interest and concern in performing nursing

care

______5. Motivated you and your family to assume gradual

responsibility for your own health care.
 _______6. Acted on your complaints immediately no matter how
trivial they ma seem.

_______ 7. Arrange for spiritual adviser, prayer groups for your

spiritual complaints and needs.

_______8. Imlpemented precautionary measures to prevent

possible complication / injury to patients (such as turning, putting
up side rails).

______9. Involved you and your family in Pre-discharge Plan

______10. Demonstrated / ensured that the health teachings

are understood and possibly done.

______11. Made necessary referrals to community agencies for

assistance.

IV. Evaluation Outcomes of Goals of Care

______1. Felt marked improvement in our physical and mental
condition

______2. Looked forward to assuming your pre- hospitalization

activities

______3. Have a brighter outlook in life

______4.Understood the nature of your illness and its effects on

your activities of daily living

______5. Know possible complication s of illness and how to

prevent them.

_____6. Ability to manage your care, gradually, independently ,

or with assistance form family.

_____-7. Performed self-care competently

 _____8. Understood the purpose of medications, treatments,
and possible side effects to be reported to the physician.

_____9. Full support and assistance given by family in performing

activities of daily living

_____10 Ability to demonstrate / repeat instructions for

continuing care at home

_____11. Identified community resources to be approached for

assistance /follow-up.

_____12. Noted schedule of return visit s to the hospital/ nearest

heath center for follow up care.