Inpatient Discharge Experience Feedback Form
Patient Name
Date of Discharge
Ward/Unit
How would you rate the communication from the staff regarding your discharge process?
Excellent
Good
Average
Poor
Very Poor
Did you understand your discharge instructions?
Yes
Somewhat
No
Were your medications explained clearly?
Yes
Somewhat
No
Were you provided with information about follow-up appointments or care?
Yes
No
Not Applicable
Did you have any concerns that were not addressed before discharge?
Do you have any suggestions for improving the discharge process?
Contact Email (optional)