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Name
   
 
 
 
Title/department
   
 
 
 
Date/time
   
 
 
 
Acknowledge (knock,announce)
 
Yes
 
No
 
N/A
 
 
 
Introduce (name,title)
 
Yes
 
No
 
N/A
 
 
 
Explanation/duration
 
Yes
 
No
 
N/A
 
 
 
Thank the patient
 
Yes
 
No
 
N/A
 
 
 
Professional and courteous
 
Yes
 
No
 
N/A
 
 
 
general appearance of room: neat,clean
 
Yes
 
No
 
N/A
 
 
 
In regards to this hospital stay, would you rate this hospital a 9-10?
 
Yes
 
No
 
N/A
 
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