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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 utmostconfidentiality, 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 nurse2 – if this is done most of the time
1 – if it is done occasionally only
0 – if it is never done.
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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.
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_____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)
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_____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.
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_______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
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_____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.