Patient Experience Reporting Portal

Province

The following information will help us understand the scope of the situation. Kindly provide as much information as you can.

Are you a patient or a caregiver?

Name of Triage Nurse

How was the reception with the FIRST person encountered? (Such as triage RN?)

Reason for this visit? (e.g., pain, fever, surgery, regular visit)

Were you in the hospital for pain crisis?

Yes

Were you admitted to inpatient ward?

Yes

How long was your hospital stay? (e.g., 5 hours, 2 days):

How familiar were the health care providers (HCP) with your condition?

How respectful were the HCPs of your needs and concerns?

Did you experience any of the following AS A RESULT of you seeking treatment during this interaction?

Stigmatization or stereotyping

Anxiety

Helplessness or Isolation

Other

Please provide details about your hospital experience.

Hospital Name

Unit or Department

Name of Physician, Nurse and other clinicians providing optimal or sub-optimal care

Your Experience

Did you receive timely medications while in the hospital?

Yes

Did you feel the right investigation/tests were conducted?

Did you feel your concerns were well addressed?

Did you feel that you had an optimal amount of time?

Is there anything else would you like us to know about this hospital interaction?

Anything else you might want to add in your own words? Use the space below to provide us with your hospital experience in 1000 words or less.

I would like to be contacted back regarding this feedback.