a i=" [ say cel eal BOY TE |T| 4] O; old MAU SO2 = a PHIEU KHAO SAT Y KIEN NGUOI BENH NGOAI TRU Nhdm muc tiéu ndng cao chat duong khém, chita bénh, dap ting sur hai long nguoi bénh, BO yté vd bénh vign 16 chite khcio sat dé tim hiéw nguyen vong nguoi bénh, Ciic ¥ kién gus bdu ndy s2 ghip ngdnh y 16 khdc phue khé khan, ting bude cai tién chat legng dé phuc vu nguedi dén tot hon. BG Y 1é bao dam giit bi mat thang tin va khong anh hueong dén viéc diéu wri. Xin tran trong cam on! L_] 1. Tén bénh vin a1: 2. Nei dién phigu....4./4/.20.2 THONG TIN NGUOI BENH Tudir «AQ. km | 2 1.C_@ Khong 3. Use tinh khoang cach tir noi sinh séng dén bénh vign: . 4.7 a cé sir dung thé BHYT cho lan khém bénh nay khong DANH GIA VIEC SU’ DUNG DICH VU ¥ TE Ong/Ba danh du gach chéo vio mOt s6 tir 1 dén 5, tong img voi mite dO hai long hose nhiin xét tir rat kém dén rat t6t cho time - © ta @ li @ ke: | @ ta | Rat khéng hai long Khdng hai long | Binh thuong Hai long | — Rat hai long hodc: Rat kem hoac: Kem I hodae: Trung binh hode: Tot hode: Rat tot A. Kha ning tiép cin a 2 A2. | Cac so dd, bién bao chi din duéng dén cae khoa, phong trong bénh vign |r rag, d& hieu, a vim: OOOH A3. | Cc khoi nha, cat thang durge danh s6 18 ring, dé tim, ©8086) g bénh vign, hanh lang bing phang, dé di COO@O8 n va dang ky Khm qua dign thoai, tang tin COaO | | fA \. [Cie bién bio, chi din dudmg dén bénh vign rd ring, dé nhin, Etim. — (OO OW ® | |_Aa | AS. [a1] Quy trinh kham én duge niém ne rd rang, cong ich, dé hidu. OO8® B2, Cae quy trinh, thir tye Kham bénh duge cai cach dom gian, than ign. O @ O@G B3 ake Ld rang, cong Khai, 10 OQOWG) a 6 gui bgnh lam ea thi tue nim no, lo ©0@® | BS. Duge xép hang theo thir te trade sau khi lim cic thit tue dang ky. n6p | bh ©90@® I B6.| Dinh gid th 08008 | B7. | Dinh gid thoi gian ché t6i hurot bac s¥ kh: dich vu y 16 nigm| 88.) Danh |B9. | Dinh 4 thot gian duye bae sy Khai va ue van, thai gian chéy Lim xét nghiém, chiéu chup. C. Co'sé vat ch be ; 1] Co phong/sanh cho kham sach 98, thong mat vio mia hé; kin gio va ae | Ap vo maa déng, \0O©O@O Phong cher 6 dii ghé nedi cho neurdi bénh va sit dung tot 10d OQ) C3. | Phong cha cd quat (digu héa) day di, hoat dong thurdng xuygn O0OOO®) | C4.’ Phong char co cic phirong tign gidp ngwoi bénh e6 tim ly thoa mai nhur |_| tievi, tranh anh, roi, nurce wong, OO@®O @ Duge bao dam su riéng wr khi kham bénh, chiéu chyp, kim thi thuat. C6. Nha vé sinh thudn cou, sur duny tt, sach s6, OOO® C7.) Méi trang trong Khudn vien bgnh vign xanh, sach, dep, O0O0O®% I T C8.! Khu khdm bénh bio dam an nin, trit ty, phong ngta tm cip cho G |__| ngudi dan, (00800 ning lye chuyén mén cita nhan vien y té during) c6 1di ndi, thai d6, giao tiép din D. Thai d9 tng vir, D1. Nhan vién y té (hae sf. di 00800 in vién phye vu (hd Ij, bao vé, Ké todn...) c6 161 néi, thai d6, giao | ding mye. OOO © Jing, quan tim, gitp ds. OO O@GE g Ive chuyén mén cua bac sf, digu dudng dap img mong dyi. ODAWE D3. Duge nhan vién y té t6n trong, déi xir cong D4. FE. Két qua cung efip dich vu EL. Ket qua kham benh da dap img duge nguyén vong cua Ong Ba. 0 @® G) ODOO® COO® O©O® £2. | Cée hoa don, phigu thu, don thude va két qua kham bénh duge cung ci day du, rd rang, minh bach va duge giai thich néu ¢6 thie mic. F anh gid chung bénh vign da dap tng duge bao nhidu % so voi mong gi trude khi toi kham bénh? | | (dién s6 tie 0% dén 100% hode c6 thé dién wen 100% néw benh vign | } digu tr] tot, vuyt qui mong dgi cia Ong/Ba) Néu cd nhu ciu kham bénb, | 1. Chie chin khong bao gid quay lai Ong/Ba cé quay tro lai hode gidi_ 2. Khong muén quay lai nhung cé it Iva chon khic thigu cho ngudi khie dén khong? | 3. C6 thé sé quay lai XIN TRAN TRONG CAM ON!sore [| alolol4]. [oe] elo] se] MAU SO 2 PHIEU KHAO SAT Y KIEN NGUOI BENH NGOAI TRU Nham muc tiéu ndng cao chat luong khdm, chita bénh, dap itng su hai long nguoi bénh, BG Y te va bénh vién t6 chitc khdo sat dé tim hiéu nguyén 1 Vong Newari bénh. Cac y kien quy bau nay sé gitip nganh y té khae phuc khé khan, ting buwée cai tién chat lugng dé phuc vu nguai dan tot hon. BG Y 16 béo dam giit bi mat thang tin va khong anh wong dén viée diéu tri. Xin tran trong cdm on! 1. Tén bénh vign: oe B. = 2. Ngay dién phiéu.WAlQ4.[lDeb.3 THONG TIN NGUOI BENE jal 1.Nam | A2 | A3.__ Use tinh khosing cach tir noi sinh sng dén bénh TAd. | Ong/Ba c6 sur dyng the BHT cho lan khém bénh nay khong? Cd _ 2. Khéng DANH GIA VIEC SU DUNG DICH VU Y TE Ong/Ba danh dau gach chéo vio mét sé tir 1 dén 5, tuong tng voi mie d6 hai long hoge nhan xét tir rat kém dén rat t6t cho timg cau hoi duéi day: : a fi © & Oki Ou | Ow | Ges] Rat khGng hai long Khdng hai long | Binh thudng Hai to Rat hai long hod: Rat kém hoge: Kem | hoge: Trung binh| hode: Tot | _ hode A. Kha nding tiép edn lOOONO chi din dudng dén cae khoa, phong trong bénh vién OOO ® ® loO8OD ____ ©909® AS. | Cé thé tim hiéu cac théng ti va ding ky khém qua dign thogi, tang tin ign tir cha bénh vign (website) thudn tign. O® g@@ © i 0 1 Eas ing, cng khai, dé hicu oo8OD WOQDOMG OOOO, eens Sas Rane eMeR ce eee) ® OOPO GO) _ 000Y®) ___ |©98O® +jh gid thoi gian duge Bs. | pi an durge be 5 kham va ur van, —___ 1OOOKR®D Banh gid thoi gian chi lim xét nghiém, chiéu chup. a OOB® &) OOOWW, Banh gid thoi Co sé vat chat va phuong tién phuc vu nguoi bénh C6 phong/sanh ch khém sach sé, thoaing mat vio mua hé; kin gid va | (5) |_| im ap vio maa dong OOO g © 120i cho nguéi bénh va sti dung tot. O@RO(< Q | Phong cha co quat (dicu hoa) day du, hout dong thuond’xuyen. sO @ @ OG Jr fing cha cé cae pha tien sip ngudi bénh c6 tam ly thoai mai nhu | [ei hevis earnest rerio ibaa ©® omO | Phong cha c6 dug! uchup, tim tha thus. [© @ Q@ COOOR OVO [C8] Khu khdm bénh bao dim an ninb, tt ty, eipiane ngita trom efip cho lo OoR © " Durge bao dim ser Nha v MGi trum, D1.| Nhan vign y t€ (bie s¥. digu dudng) 66 Iai a 9, wiao tip din a mye OOONO D2. Nhan vin phue vy (hg ly, bio vg, ké todn...) e6 li noi, thai d9, giao | tigp ding myc. COO® © Duge nhan vign y 16 t6n trong, déi xis cong % \OOQ® SJ, digu dutng dip img mongdgi. (OO OOS) 1g lye chuy, mon etta E. Két qua cung cap dich vy cones | Két qua khm bénh da dap ing duge nguyén vong cua Ong/Ba. lo OO’ © 1 thu, don thude vi két qua khim bénh duge cung cap © OQO © luge giai thich néu cé 1 3. | Danh gia mite do tin trong vé chat long dich vy y te _OO@ ® E4, | Banh gié mire d6 hai long vé gid ea dich vy y té OOOW F anh gid chung bénh vign da dp ting duge bao nhicu % so véi mong gi trade khi t6i khdim benh? 90. (dién $6 tir 0% dén 100% hode c6 thé dién trén 100% néu bénh vign | diéu tr tét, woot quid mong doi cia Ong/Ba) aes 3 hu edu khém_bénh, | 1. Chie chin kh6ng bao gid quay lai Ong/Ba c6 quay tr6 lai hode gidi | 2. Khéng mudn quay lai nhung cé it Iya chon khéc thigu cho ngudi khae dén khOng? | 3. C6 thé sé quay lai G / 3 Chae chan sé quay lai hoje gidi thigu cho ngudi khae es oekchie (S00) XIN TRAN TRONG CAM ON!BOY TE MAU SO2 PHIEU KHAO SAT Y KIEN NGUOIL BENH NGOAI TRU. Nhim muc tiéu nang cao chat rong khém, chica bénh, dap ing sir hai tong nguoi benh, Bo Y te vii bénh vién 16 chite khao sat dé tim hiéu nguyén vong ngudi benh. Ciic ¥ kién quy bau nay s€ giuip ngdinh y 16 Khe phue kho khan, timg bude cai tién chat wong dé phuc vu ngwdi din t6t hon. BOY 16 bio dm giit bi mgt thang tin va khong anh Ineong dén viée diéu iri. Xin wrén trong cém on! 1, Tén bénh vign: «2... aA 2. Neay dién phiéu.ohthty/Zd THONG TIN NGUOIBENH Al. |Giditinh: YANam 2.Ni | A2. | Tui: DE... [A3.__ Use tinh khoang cach tir noi sinh séng dén bénh vign: .. dh. d...km 1 Co: Kho SU DUNG DICH VU Y Ong/Ba dinh dau gach chéo vio mgt sé tir 1 dén 5, tuong ting voi mite d6 hai long hode nhan xét tir rat kém dén rat tot cho tim cau hoi dudi day: aa © a Ou Ot | Rat khong hai long Khong hai long | Binh thudng Hailéng | Rat hai long hhodic: Rit kem hoge: Kem | hoge: Trung binh| hode: Tot | hode: Rat tot im —— i 3 rang, dé nhin, dé tim. oro) mn lOOo® & 6) in dong dn cd Khoa, phong rong bénh ven | o> @ @ G) 6 13 ring, d& tim ©OB® A3. | Cac khdi nha, cau thang durge danh sé hanh lang bing phang, dé di O® oe A. Kha ning ti AL. | Cae bién bi je I t ‘de so dd, bién bao ehi | 3 rang, dé higu, dé tim AA. | Cac Idi di trong bénb v AS. | Cé thé tim hiéu cdc thong tin va ding ky khém qua dign thoai, tang tin | | dign tir eiia bénh vign (website) thudn tién, | I | |_B. Sy minh bach thong tin v LB | Quy trinh khém bénh duge niém yét rO rang, céng khai, dé hicu. } 12 | Ce quy rink, hina ksi bo ge cl cch dom gin, chun tig, xc xép hang theo thir ty truéc sau khi kim ede thi tue dang ky, nép | | idm, Khim benb, x6t nghigm, chi oO GO®B8. | Dinh gid thoi gian duge bie Bd. | Banh BIO. ci kham va we ia thai gian chi lam xét nghiém, chiéu chup, C4 Trceg cars crema asc Gea Bearer tam ly thoai mai nh | ti-vi, tranh anh, ta roi, nude uéng. OOORO) Dara hao dam su rié Nha vg sinh thud: g th, dep. C8. Khu kham bénh bao dam an ninh, tat ty, phong ngita trom cip cho 0OO® 6) ngudi dan, D2.’ Nha vign phue vy (hd ly, bio vé, Ké tod...) ¢6 Toi ndi, thai d6, giao | p dang mye 'O® oe 29 D3. Duge nhdn vién y té tn trong, doi xtc cong bang, quan tam, gidp da, OO®D D4. Nang lye chuyén mon cua bac sf, dicu dung dap img mong doi. lo@®®@ E. Két qua cung BL. | Két qua km bénh d ip img duge nguyén vong cia Ong/Ba. OO® 2. Cae hoa don, phigu thu, don thude va két qua kham bénh due eung ep o eo | day di, r6 rang, minh bach va duge giai thich néu co # 5 39 i) E3. | Dinh gid mite dé tin uromg vé chat Iugng dich vu y té 6 ® 38 8 5 on aT een) a £4. | Danh gid mite dé hai long ve F | Dinh gid chung bénh vign dd dap dng duge bao nhigu % so voi mong | dgi trude khi toi khim bénh? (dién 36 tie 0% dén 100% hode 6 thé didn trén 100% néu bénh vién | | didu tri t6t, vrgt qué mong doi ctia Ong/Ba) Aedl..% G | Néu cé nhu ciu khim bénh, | 1. CI ng/Ba c6 quay tro Iai hoa thigu cho new! khie dén khéng chin khong bao wits quay Iai 2. Khong muon quay lai nhung cé it Iya chon khac CO thé sé quay lai 4, Chae chan sé quay lai hoge gidi thi | 5. Khe (ghi 3)... cho ngudi kha =) XIN TRAN TRONG CAM ON!BOY TE #4 MAU SO2 PHIEU KHAO SAT Y KIEN NGUOI BENH NGOAI TRU Nhdm mue tiéu nang cao chat heong khim, chita bénh, dap ing sw hai long ngudi bénh, BOY te vd bénh vign 16 chitc khiio sit dé tim hiéu nguyén vong nguedi bénk, Cac ¢ kién guy baw nay sé gitip ngdnh y té khac phue khé khan, vieng bude cdi tién chat leong dé phue vu ngudi dan t6t hon. Bo Y 16 hao dam giit bi mat thong tin va khong anh Incong dén viée diéu tri. Xin tran trong cdm on! kien 2 2. Neay dién phiéu..S// 028 JONG TIN NGUOI BENE 2.Nir a2. [Tudi: ... 2.4. f rane | A3 _UGe tinh khoang cach tir noi sinh song den bénh vicn: 4,5... km lesa Ong/Ba cé sit dung the BHYT cho lan khém bénh nay khéng? (1.€6,) 2. Khang | Al. Giditinh DANH GIA VIEC SU DUNG DICH VU Y TE. Ong/Ba dinh di gach chéo vio mot s6 tir 1 dén 8, twong ing vi mie dé hai long hoge nhan xcx tir rt kém dén rat t6t cho timg ow | @w] G) li © | Rat khong hai long | Khong hai long | Binh thiémg | Hailing | Rat hai long hodc: Ratkém« | ode: Kém | hode: Trung binh| hod: T | hode: Rat tot U8 nhin, A tim, oD o6® 6) cite khoa, phong trong bénh vign 5 oO ®@ @ (A. Kha nang Al Cae bien b ee : | Cée 16% di trong bénb vign, hainh k AS. | Cé thé tim higu cac thong tin va dang ky khdm qua dign thoai, trang tin |_| dign ti etia bénh vign (website) thudn tign um" 10 © GOO T BI B3. | Gia dich vy y té niém yat ro rang, céng khai OCDOW BA, | Nhin vién y té tgp don. hiring din nguoi bénh kam cae th we niem no, . @E) | tan tinh 0OFXO® BS. | Duge xép hang theo thir ty trude sau khi lim cde thi tue ding ky. nép | tign, khdm bénh, xét nghigm, chiéu chup. 0008 6. | Dinh gi thai gian ch dai im thi tue dng ky Kham. OOOO) gid thoi gian chi ti lwot bae SV kham, 100 OO’B9. | Dinh gid thoi gian chi him xét nghiém, chigu an B10. Danh C. Corsé vat chat va phwong ¢ C1.) Co phong/sanh cho kham sach s&, thoang mat vao mua he; kin gid va | a Ap vao mita dong. “© © WE 4 théi gian cho nhan két qua xét nghiém, chiéu chyp. O@ n phyc vy ngwoi bénh C2. Phong cho c6 du ghé ngoi cho ngudi bénh va sir oud tot C3. Phan Seager aee _ | Phong eh 66 cde phuong tign piép ngwdi bénh o6 tm Ij thodi méi ah "'0OBOO tivi, tranh anh, ta roi, nude uéng, | QQOB® ae Ow BS 8 sank ODO” C8.) Khu khdm bénh bao dam an ninh, trat ty, phong ngira trom cap cho nui dn DOVOO chi co quat (dicu hoa) Duge bao dim D. Thai do eng vir, u DI.) Nhan vien y 1 (bac sy, dicu dudng) co di noi, thai do, giao tigp dung, | lOOROO in ding mie. 12, di xtt cong bing, quan t E forolol 8 -digu dudng dip mg mong do OR OO) __ oO BOO) ic hoa i phiéu thu, don thude va két qua kham bénh durge cung cap 0OOMO) sim Denk du 6 | DaagG) © Q Ow chung bénh vign di dap tg duge bao nhiéu % so voi mong, dgi trude khi toi kham bénh? EK. % | (aién 86 tie 0% dén 100% hode cd thé dién trén 100% néu bénh vién | | diéu tri t6t, vuegt qua mong doi ciia Ong/Ba) | ll G | Néu cé nhu cau kham bénh, | 1. Chac chan khong bao gid, igs quay lai Ong/Ba c6 quay tr6 lai hode gidi | 2. Khéng mudn quay lai nhumg cé it Iya chon khae | thigu cho nguor khae dén khong? s8 quay lei | ‘ic chan sé quay lai hod giéi thjéu cho ngudi khac | | 5. Khac (ghi 13)... ‘ pene XIN TRAD TRONG CAM ON!lololaisla! BOY TE MAU S02 PHIEU KHAO SAT Y KIEN NGUOI BENH NGOAL TRU Nhdm muc tiéu ndng cao chat long khim, chita bénh, dap ting st hai long nguéi bénh, BO Y té vi bénh vign t6 chive khiio sat dé tim hieu nguyén vong ngudi hénh. Céc y kién guy: bau nay sé ghip nganh y té khiée phuc kh khén, ting bude cdi tién chat wong dé phuc vu ngwai dain t6t hon. BG Y 16 hao dam git bi mat thong tin va khong anh hwong dén vige dicu tri. Xin tran trong cam on! 1. Ten bénh vién: .. 2. Ngay dién phiéu...8.4./.2, 1202 > THONG TIN NGUOI BENH [AL | Giditinh: 1. Nam @ Ne [A2. | Tudis GR. | LAB. Use t h khoaing (Aa. | Ong/ tr dung the BHY'T cho lan kham bénh nay khong? (T)Co 2. Khong | ‘h tir noi sinh séng dén bénh vién: ...7,4.....km DANH GIA VIEC SU DUNG DICH VU Y TE Ong/Ba danh diu gach chéo vio mét sé tir 1 dén 5, trong ing voi mite 46 hai long hoje nhiin xét tir rat kém dén rt tot cho timg edu hoi dudi day: © te Oe @u @i G6) | O © | @ 8 es LY Rat khong hai long Khong hai ling | Binh thuong Halong | Rat hai long hode: Ratkem | hoe: Kem _| hod: Trung binh) hode: Tt) _ hoge: Rat t6t ~A. Kha niing tigp cn |_AL.| Cac bién bio, chi din dong dén bénh vign 3 rang, dé nhin, dé tim OM OOD Ea z { A2.| Cac so dd, bién bio chi din dudng dén cac khoa, phong trong bénh vign - ; "0®@ 008 a inh s6 ro ring, dé tim. u thang due ping, 48 di __ OQ AS. C6 thé tim hid n va ding ky khim qua dién thoai. tran: |_| dign tir cita bénh vign (website) thudin tiga A3. | Cae khoi nha, ES | Cac 16i di trong bénb vign, hanh ta g tin va thd tye kham bénh, diéu tri B. Sy minh bach t | BL. | Quy trinh kham bénh duoe niém yet r6 rang, céng khai, dé hicu. | 82. | Cae quy trinh, tha tue khim bénh duge edi each don gidn, thud tign | 83. Gia dich vu y nim yét 16 rang, cdng khai | 384. Nin vign yt tiép don, hung dn nguor beni lm eae thu wwe mim NO. I. (5) tan tinh. ye xép hang theo thir ty trude sau khi kim ede this tye dang ky, nop ~) tin, kham bénh, xét nghiém, chiéu chup. OOOW®D | Bo. | banh wid thar wian cher doi kam thi tue ding ky kha. @O000O0 ___ 89 96®BS. | Banh gid thoi gian due bie sf kam vi tw va B9. | Dinh gid thoi gian chi Kim xét nghiém, chigu chup. | B10. Dinh gia thai gian cho nhiin két qua xét nghigm, chiéu chup. C. Co'sé vat chat va phuung tign phyc vy n | | eo ae ae eta sach sé, thoang = vao mita he; kin gid va 0QO@ @ Goh vasidungi. COO® &) | Phong chi e6 quat (didu hoa) diy di, hoat dong thudng suyén. CODE C4. | Phong che ¢6 cdc phurong tign gitip ngudi bénh co tam ly thoai mai nhur | bee 5 08000) ‘vi, ranh anh, W roi, nude udng... chyp, im thathuat. OO @&G ____ |18@O@ 0080 C8. Khu khém bénh bao dam an ninh, trdt ty, phong ngira trom cap cho gus din \0O®OO® g tign phye vy nguii bi Phong ché cé du yhé ngdi cho ngudi ir dung t6t, sach sé C6. | Nha vé sinh thudin tigi °7. | Moi trudng trong khudn vign bénh vign xanh, sach, de; D. Thai d6 ting vir, nding lye chuyén mén cia hain vien y té D1. | Nhan vién y té (bac s¥, diéu dudng) c6 loi noi, thai 46. giao tiép ding | [me 0090@® D2. Nhan vién phuc vy (hd ly, bao vé, ké toan....) c6 1di ndi, thai dd, giao - tiép dang myc. 0©0@®) Buge nhan vign y té ton trong, doi xiz cong bing. quan tim, giup dé. © @) G) &) G) mon cua bac sf, digu dudng dap ing mong di. OO® dich vy 0 008® ‘ie hoa don, phigu thy, don thude va két qué kim enh durge eung cE G BO) 3. | Danh gid mire do tin trong ve chat lugng dich vu y te. | gid mite do 1g ve chat lugng dich vu y OOO® & gid ca dich vu y té OOOOH) Danb gid chung bénh vign da dap tng duge bao nhiéu % so véi mong dgi true khi toi kham bénh? CO. | anh gid mite dé hai lon, (dién $6 tir 0% dén 10% hode ¢6 thé dién tren 100% néu bénh vign diéu tri tot, vut qua mong doi cua Ong/Ba) G | Néu co nhu cau kham bénbh, | 1. Chdc chin khong bao gid quay lai ng/Ba c6 quay tro lai hode vidi (Z)Khong mudn quay lai nhung cé it Iya chon khéic thigu cho ngudi khae dén khong? "3. C6 thé sé quay lai 4. Chic chin sé quay lai hod - Khac (ghi 13). | gidi thigu cho ngudi khac | | | XIN TRAN TRONG CAM ON!