Hospital Discharge Feedback Form
This hospital discharge feedback form captures the critical patient experience during the care transition period. It evaluates clarity of discharge instructions, medication understanding, pain management preparation, follow-up appointment coordination, and overall readiness to go home. The form uses patient-friendly language and adapts questions based on responses to identify specific areas needing improvement.
Try the Form
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export function hospitalDischarge(form: FormTs) {
// Hospital Discharge Feedback Form
// Demonstrates: RatingScale (Likert), MatrixQuestion, StarRating, EmojiRating,
// CheckboxList, Slider, conditional visibility, patient-friendly design
// ============================================
// STATE
// ============================================
const overallReadiness = form.state<string | null>(null);
const instructionClarity = form.state<number | null>(null);
// ============================================
// HEADER
// ============================================
form.addRow(row => {
row.addTextPanel('header', {
label: 'Discharge Experience Survey',
computedValue: () => 'Help us improve the discharge process for future patients.',
customStyles: {
background: 'linear-gradient(135deg, #0ea5e9 0%, #0284c7 100%)',
color: 'white',
padding: '24px',
borderRadius: '12px',
textAlign: 'center',
fontSize: '14px'
}
});
});
// ============================================
// SECTION 1: OVERALL READINESS
// ============================================
const readinessSection = form.addSubform('readinessSection', {
title: 'Overall Readiness',
customStyles: {
backgroundColor: '#f0f9ff',
padding: '16px',
borderRadius: '8px'
}
});
readinessSection.addRow(row => {
row.addEmojiRating('readinessFeeling', {
label: 'How ready did you feel to leave the hospital?',
preset: 'satisfaction',
size: 'lg',
alignment: 'center',
onValueChange: (v) => overallReadiness.set(v ?? null)
});
});
readinessSection.addRow(row => {
row.addRatingScale('overallDischarge', {
label: 'Rate your overall discharge experience:',
preset: 'satisfaction',
alignment: 'center'
});
});
// ============================================
// SECTION 2: DISCHARGE INSTRUCTIONS
// ============================================
const instructionsSection = form.addSubform('instructionsSection', {
title: 'Discharge Instructions',
isVisible: () => overallReadiness() !== null,
customStyles: {
backgroundColor: '#ecfdf5',
padding: '16px',
borderRadius: '8px'
}
});
instructionsSection.addRow(row => {
row.addRatingScale('instructionClarity', {
label: 'How clear were your written discharge instructions?',
preset: 'likert-5',
lowLabel: 'Very unclear',
highLabel: 'Very clear',
alignment: 'center',
onValueChange: (v) => instructionClarity.set(v ?? null)
});
});
instructionsSection.addRow(row => {
row.addMatrixQuestion('instructionTopics', {
label: 'How well were these topics explained?',
rows: [
{ id: 'medications', label: 'Medications to take', isRequired: true },
{ id: 'warning', label: 'Warning signs to watch for' },
{ id: 'restrictions', label: 'Activity restrictions' },
{ id: 'diet', label: 'Diet instructions' },
{ id: 'wound', label: 'Wound/incision care' },
{ id: 'followup', label: 'Follow-up appointments' }
],
columns: [
{ id: 'notApplicable', label: 'N/A' },
{ id: 'poor', label: 'Poor' },
{ id: 'fair', label: 'Fair' },
{ id: 'good', label: 'Good' },
{ id: 'excellent', label: 'Excellent' }
],
fullWidth: true
});
});
instructionsSection.addRow(row => {
row.addThumbRating('instructionWritten', {
label: 'Did you receive written instructions to take home?',
showLabels: true,
upLabel: 'Yes',
downLabel: 'No',
alignment: 'center'
});
});
// Follow-up if instructions were unclear
const unclearSection = instructionsSection.addSubform('unclearSection', {
isVisible: () => (instructionClarity() ?? 0) <= 2 && instructionClarity() !== null
});
unclearSection.addSpacer({ height: '16px' });
unclearSection.addRow(row => {
row.addCheckboxList('unclearAreas', {
label: 'Which areas were unclear?',
options: [
{ id: 'meds', name: 'Medication schedule' },
{ id: 'dosage', name: 'Medication dosages' },
{ id: 'symptoms', name: 'What symptoms to watch for' },
{ id: 'emergency', name: 'When to seek emergency care' },
{ id: 'activities', name: 'What activities to avoid' },
{ id: 'appointments', name: 'Follow-up appointment details' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 3: MEDICATION UNDERSTANDING
// ============================================
const medicationSection = form.addSubform('medicationSection', {
title: 'Medication Understanding',
isVisible: () => instructionClarity() !== null
});
medicationSection.addRow(row => {
row.addRadioButton('newMedications', {
label: 'Were you prescribed new medications at discharge?',
options: [
{ id: 'yes', name: 'Yes' },
{ id: 'no', name: 'No' },
{ id: 'unsure', name: 'Not sure' }
],
orientation: 'horizontal'
});
});
const newMedsSection = medicationSection.addSubform('newMedsSection', {
isVisible: () => medicationSection.radioButton('newMedications')?.value() === 'yes'
});
newMedsSection.addRow(row => {
row.addStarRating('medExplanation', {
label: 'How well were your new medications explained?',
maxStars: 5,
size: 'lg',
alignment: 'center'
});
});
newMedsSection.addRow(row => {
row.addMatrixQuestion('medicationKnowledge', {
label: 'Do you understand the following about your medications?',
rows: [
{ id: 'purpose', label: 'What each medication is for' },
{ id: 'timing', label: 'When to take each medication' },
{ id: 'sideEffects', label: 'Possible side effects' },
{ id: 'interactions', label: 'What to avoid while taking them' }
],
columns: [
{ id: 'no', label: 'No' },
{ id: 'somewhat', label: 'Somewhat' },
{ id: 'yes', label: 'Yes' }
],
fullWidth: true
});
});
// ============================================
// SECTION 4: PAIN MANAGEMENT
// ============================================
const painSection = form.addSubform('painSection', {
title: 'Pain Management',
isVisible: () => medicationSection.radioButton('newMedications')?.value() !== null
});
painSection.addRow(row => {
row.addRadioButton('painAtDischarge', {
label: 'Did you have pain when leaving the hospital?',
options: [
{ id: 'none', name: 'No pain' },
{ id: 'mild', name: 'Mild pain' },
{ id: 'moderate', name: 'Moderate pain' },
{ id: 'severe', name: 'Severe pain' }
],
orientation: 'horizontal'
});
});
const painManagementSection = painSection.addSubform('painManagementSection', {
isVisible: () => {
const pain = painSection.radioButton('painAtDischarge')?.value();
return pain !== null && pain !== 'none';
}
});
painManagementSection.addRow(row => {
row.addSlider('painControlConfidence', {
label: 'How confident are you in managing your pain at home?',
min: 1,
max: 10,
step: 1,
showValue: true,
defaultValue: 5
});
});
painManagementSection.addRow(row => {
row.addCheckboxList('painResources', {
label: 'What pain management information did you receive?',
options: [
{ id: 'schedule', name: 'Pain medication schedule' },
{ id: 'alternatives', name: 'Non-medication pain relief options' },
{ id: 'emergency', name: 'When to call for severe pain' },
{ id: 'refills', name: 'How to get refills if needed' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 5: FOLLOW-UP CARE
// ============================================
const followupSection = form.addSubform('followupSection', {
title: 'Follow-Up Care Coordination',
isVisible: () => painSection.radioButton('painAtDischarge')?.value() !== null
});
followupSection.addRow(row => {
row.addThumbRating('appointmentScheduled', {
label: 'Was a follow-up appointment scheduled before you left?',
showLabels: true,
upLabel: 'Yes',
downLabel: 'No',
alignment: 'center'
});
});
followupSection.addRow(row => {
row.addRatingScale('careCoordination', {
label: 'How well was your transition to home care coordinated?',
preset: 'likert-5',
lowLabel: 'Very poorly',
highLabel: 'Very well',
alignment: 'center'
});
});
followupSection.addRow(row => {
row.addCheckboxList('supportServices', {
label: 'Were you connected with needed support services?',
options: [
{ id: 'homeHealth', name: 'Home health care' },
{ id: 'pt', name: 'Physical therapy' },
{ id: 'pharmacy', name: 'Pharmacy services' },
{ id: 'equipment', name: 'Medical equipment' },
{ id: 'none', name: 'No additional services needed' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 6: STAFF COMMUNICATION
// ============================================
const staffSection = form.addSubform('staffSection', {
title: 'Staff Communication',
isVisible: () => followupSection.thumbRating('appointmentScheduled')?.value() !== null
});
staffSection.addRow(row => {
row.addStarRating('nurseExplanation', {
label: 'How well did nursing staff explain your discharge care?',
maxStars: 5,
size: 'md',
alignment: 'center'
}, '1fr');
row.addStarRating('doctorExplanation', {
label: 'How well did doctors explain your condition and care?',
maxStars: 5,
size: 'md',
alignment: 'center'
}, '1fr');
});
staffSection.addRow(row => {
row.addRadioButton('questionsEncouraged', {
label: 'Did staff encourage you to ask questions?',
options: [
{ id: 'yes', name: 'Yes, and I felt comfortable asking' },
{ id: 'somewhat', name: 'Somewhat, but felt rushed' },
{ id: 'no', name: 'No, I felt I couldn\'t ask questions' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 7: ADDITIONAL FEEDBACK
// ============================================
const feedbackSection = form.addSubform('feedbackSection', {
title: 'Additional Feedback',
isVisible: () => staffSection.starRating('nurseExplanation')?.value() !== null
});
feedbackSection.addRow(row => {
row.addRadioButton('hadProblems', {
label: 'Have you experienced any problems since leaving the hospital?',
options: [
{ id: 'no', name: 'No problems' },
{ id: 'minor', name: 'Minor issues, resolved' },
{ id: 'ongoing', name: 'Ongoing concerns' },
{ id: 'emergency', name: 'Had to seek emergency care' }
],
orientation: 'vertical'
});
});
feedbackSection.addSpacer({ height: '16px' });
feedbackSection.addRow(row => {
row.addTextarea('additionalComments', {
label: () => {
const problems = feedbackSection.radioButton('hadProblems')?.value();
if (problems === 'ongoing' || problems === 'emergency') {
return 'Please describe the problems you experienced:';
}
return 'Any additional comments about your discharge experience?';
},
placeholder: 'Your feedback helps us improve care for future patients...',
rows: 4,
autoExpand: true
});
});
// ============================================
// SECTION 8: SUMMARY
// ============================================
const summarySection = form.addSubform('summarySection', {
title: 'Feedback Summary',
isVisible: () => feedbackSection.radioButton('hadProblems')?.value() !== null
});
summarySection.addRow(row => {
row.addTextPanel('summaryPanel', {
computedValue: () => {
const readiness = overallReadiness();
const clarity = instructionClarity();
const coordination = followupSection.ratingScale('careCoordination')?.value();
const problems = feedbackSection.radioButton('hadProblems')?.value();
const readinessLabels: Record<string, string> = {
'very-bad': 'Not ready',
'bad': 'Slightly unprepared',
'neutral': 'Somewhat ready',
'good': 'Ready',
'excellent': 'Very ready'
};
let emoji = '🏥';
if (clarity && clarity >= 4 && (readiness === 'good' || readiness === 'excellent')) {
emoji = '✅';
} else if (problems === 'emergency') {
emoji = '🚨';
} else if (problems === 'ongoing') {
emoji = '⚠️';
}
let summary = `${emoji} Discharge Experience Summary\n`;
summary += `${'═'.repeat(30)}\n\n`;
summary += `🏥 Readiness: ${readiness ? readinessLabels[readiness] || readiness : 'Not rated'}\n`;
summary += `📋 Instruction Clarity: ${clarity ? clarity + '/5' : 'Not rated'}\n`;
summary += `🤝 Care Coordination: ${coordination ? coordination + '/5' : 'Not rated'}\n`;
summary += `📊 Post-discharge: ${problems === 'no' ? 'No problems' : problems === 'minor' ? 'Minor issues' : problems === 'ongoing' ? 'Ongoing concerns' : problems === 'emergency' ? 'Emergency visit required' : 'Not specified'}`;
return summary;
},
customStyles: () => {
const problems = feedbackSection.radioButton('hadProblems')?.value();
const baseStyles = {
padding: '20px',
borderRadius: '8px',
whiteSpace: 'pre-wrap',
fontFamily: 'monospace',
fontSize: '13px'
};
if (problems === 'emergency') {
return { ...baseStyles, backgroundColor: '#fee2e2', borderLeft: '4px solid #ef4444' };
}
if (problems === 'ongoing') {
return { ...baseStyles, backgroundColor: '#fef3c7', borderLeft: '4px solid #f59e0b' };
}
return { ...baseStyles, backgroundColor: '#dcfce7', borderLeft: '4px solid #22c55e' };
}
});
});
// ============================================
// FORM CONFIGURATION
// ============================================
form.configureSubmitButton({
label: 'Submit Feedback',
isVisible: () => feedbackSection.radioButton('hadProblems')?.value() !== null
});
form.configureCompletionScreen({
type: 'text',
title: 'Thank You for Your Feedback',
message: () => {
const problems = feedbackSection.radioButton('hadProblems')?.value();
if (problems === 'emergency' || problems === 'ongoing') {
return 'We\'re sorry to hear about your difficulties. A patient care coordinator will review your feedback and may reach out to ensure you\'re getting the support you need.';
}
return 'Your feedback helps us improve the discharge experience for all patients. We wish you a speedy recovery!';
}
});
}
Frequently Asked Questions
When should patients receive this survey?
Send 24-48 hours after discharge, when the experience is fresh but the patient has had time to settle at home and potentially encounter any instruction issues.
How does this relate to HCAHPS?
This survey complements HCAHPS by providing detailed discharge-specific feedback. While HCAHPS includes discharge questions, this form goes deeper into instruction clarity, medication understanding, and follow-up coordination.
What's the connection to readmission rates?
Poor discharge experiences often correlate with higher readmission rates. Patients who don't understand their instructions or medications are more likely to return. This survey helps identify and address these gaps.
Should I customize questions for different departments?
Yes, consider tailoring questions for specific departments (surgery, maternity, cardiac, etc.) as discharge needs vary significantly. Use conditional logic to show relevant questions.
How can I improve response rates?
Keep the survey focused and under 5 minutes. Send via the patient's preferred channel (email or SMS). Consider offering a summary of discharge instructions as an incentive for completion.