Feedback Module

* When did the event occur?

Question *When did the event occur? is required

* Patient First Name:

Question *Patient First Name: is required

* Patient Last Name:

Question *Patient Last Name: is required

* Patient Date Of Birth: (MM/DD/YYYY)

Question *Patient Date Of Birth: (MM/DD/YYYY) is required

* Event Type:

Question *Event Type: is required

* Type of complaint or compliment:

Admissions/Appointment Process

Other Resident/Patient

Behavior/Attitude

Pain Management

Billing/Insurance

Patient/Resident Rights

Communication

Privacy/Confidentiality

Cultural/Spiritual Sensitivity

Promptness of Tests/Treatments

Diagnosis - Failure to/Misdiagnosis

Quality of Care

Discharge Process

Reportable

Environment

Roommate

Equipment

Safety/Security

Food

Scheduling Error

Medication Related

Wait Time

Missing items

Other

Question *Type of complaint or compliment: is required

* Specify 'Other' complaint or compliment:

Question *Specify 'Other' complaint or compliment: is required

* Sub Event Type:

Question *Sub Event Type: is required

Where did the event occur? (delete)

* Location:

Question *Location: is required

* Sub-Location:

Question *Sub-Location: is required

* Please specify 'Other' sub location

Question *Please specify 'Other' sub location is required

* Sub-Sub-Location:

Question *Sub-Sub-Location: is required

Specific Location:

Question *Specific Location: is required

* Please specify "Other" sub-sub-location:

Question *Please specify "Other" sub-sub-location: is required

Specific Location

Question *Specific Location is required

Do you feel another department has involvement with or needs notification of this event?

Yes

Question *Do you feel another department has involvement with or needs notification of this event? is required

* Name of person making complaint or compliment:

Question *Name of person making complaint or compliment: is required

Address, City, State, Zip Code:

Question *Address, City, State, Zip Code: is required

Relationship to patient:

Self

Family

POA/Guardian

Visitor

Other

Question *Relationship to patient: is required

* Specify 'Other' relationship to the patient:

Question *Specify 'Other' relationship to the patient: is required

* Describe the event: (facts only please)

Question *Describe the event: (facts only please) is required

Witnesses:

Question *Witnesses: is required