Patient Satisfaction Survey
This survey template empowers healthcare professionals to gauge patient satisfaction with their medical care quickly and effectively. It can be administered via self-service kiosks or staff-operated mobile devices to capture real-time feedback.
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How to Use This Checklist
- Decide where the survey will be offered — a self-service kiosk or staff-operated mobile devices — and who will present it to patients.
- Record the administrative details first: the date it was conducted, who prepared it, and the location.
- Ask the patient to rate each statement on the five-point scale, from Strongly Agree through to Strongly Disagree.
- Use the open comment field to capture anything the statements did not cover, or to let the patient explain a rating.
- Record the signature, the Finished At timestamp, and the inspection's real start and end dates.
- Read the responses together as a set and look for recurring issues rather than one-off ratings.
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Patient satisfaction survey
A patient satisfaction survey asks patients to assess the medical care they have received. Rather than measuring the care from the inside, it records the patient's own experience of it: whether their concerns were taken seriously, whether things were explained to them, whether they could get the care they needed, and whether the cost of that care was manageable. This survey template is built to be administered quickly. It can be presented on a self-service kiosk or on a staff-operated mobile device, so feedback can be captured in real time while the visit is still fresh.
Why collecting patient feedback matters
Feedback from patients shows how care is actually experienced, which is not always visible from clinical records alone. It can surface problems with communication, access or affordability that affect whether patients return, follow advice, or recommend the service. This template includes a statement on overall satisfaction — "Overall, I am satisfied with the medical care I receive" — alongside questions that get at the specific factors behind that overall judgment.
What the survey covers
The statements in this template group around a few broad themes: - **Communication.** Whether doctors thoroughly explain the reasons for medical tests and procedures, communicate diagnoses with clarity and confidence, actively listen and take concerns seriously, and dedicate sufficient time to address concerns during each visit. - **Quality and capability.** Whether the doctor's practice is equipped with everything necessary for comprehensive medical care, whether the quality of medical care received is rated excellent, and whether wait times for urgent or emergency care are reasonable. - **Access.** Whether it is easy to schedule a timely appointment, whether the patient can access medical care whenever they need it, and whether they have easy access to the medical specialists they need. - **Affordability.** Whether the patient is confident they can receive necessary medical care without experiencing financial hardship, and whether the cost of their medical care remains within what they can reasonably afford. - **Care and respect.** Whether providers are friendly, respectful and accommodating, take their time without rushing, and treat the patient with warmth and a personal touch rather than only professionally. - **Confidence and overall satisfaction.** Whether the patient has full confidence in the medical expertise of their treating physicians, and whether they are satisfied with the medical care overall.
What a good survey covers
A useful patient satisfaction survey does more than ask whether the patient was happy. It separates the components of the experience so that a poor overall rating can be traced to a specific cause — a rushed appointment, an unclear explanation, an unaffordable bill, or a long wait for an appointment or for specialist care. This template also leaves room for the patient's own words through an open field for additional comments or feedback. An open field often captures what a rating scale cannot: the specific incident, the specific delay, or the specific member of staff.
How to use the template
Decide where the survey will be offered — a self-service kiosk or staff-operated mobile devices — and who will present it to patients. Record the administrative details first: the date it was conducted, who prepared it, and the location. Then ask the patient to rate each statement on the five-point scale, from Strongly Agree through to Strongly Disagree. Use the open comment field to capture anything the statements did not cover, or to let the patient explain a rating. Record the signature, the Finished At timestamp, and the inspection's real start and end dates. Once responses are in, read them together as a set. Recurring ratings on the same statement are more informative than any single response, and a pattern of comments on the same theme is the clearest signal of where to act first.
Turning the results into action
Because the statements map to distinct parts of the experience — explanation, listening, timeliness, scheduling, cost, and access to specialists — you can direct improvement effort rather than broadly attempting to raise satisfaction scores. The repeated comments left in the open field are often the most actionable part, since they describe what actually happened.
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