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Exit Survey
 
 
Date
MonthDayYear
  
 
 
 
Staff Name
   
 
 
 
white board updated?
 
 
 
Hourly rounding Log updated?
 
Yes
 
No
 
N/A
 
 
 
Are we taking care of your needs?
 
Yes
 
No
 
N/A
 
 
 
Are the staff 'hourly rounding'?
 
Yes
 
No
 
N/A
 
 
 
Are the staff answering the call light?
 
Yes
 
No
 
N/A
 
 
 
Did the nurse change shift at the bedside?
 
Yes
 
No
 
N/A
 
 
 
Did they include you during shift change?
 
Yes
 
No
 
N/A
 
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