Hospital Discharge Experience Survey

Hospital Discharge Experience Survey — Form Fields

This surveys template includes 8 fields. Collect patient feedback on discharge instructions, support provided, and transition to home care. Free to customize and use on ZenBuild.

• Length of Hospital Stay (dropdown selection, required) — options: 1-2 days, 3-5 days, 6-10 days, More than 10 days
• Overall Hospital Experience (rating, required)
• Discharge Instructions Clarity (rating, required)
• Staff Helpfulness at Discharge (rating, required)
• Readiness to Go Home (rating, required)
• Did you understand your follow-up care plan? (multiple choice, required) — options: Completely, Mostly, Partially, Not at All
• Support Provided at Discharge (checkboxes, optional) — options: Written Instructions, Medication List, Follow-Up Appointments, Equipment Provided, Home Care Referral
• How can we improve the discharge process? (long text, optional)