Patient Satisfaction Survey
This patient satisfaction survey is designed for healthcare providers to measure and improve patient experience. Based on HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) methodology, it covers key dimensions including nurse and doctor communication, staff responsiveness, pain management, discharge information, and facility cleanliness. The form uses validated rating scales and includes conditional follow-up questions to gather actionable insights.
Try the Form
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export function patientSatisfaction(form: FormTs) {
// Patient Satisfaction Survey - Healthcare feedback based on HCAHPS methodology
// Demonstrates: MatrixQuestion, RatingScale (Likert), Slider, conditional sections, multi-page potential
// ============================================
// HEADER
// ============================================
form.addRow(row => {
row.addTextPanel('header', {
label: 'Patient Experience Survey',
computedValue: () => 'Your feedback helps us provide better care',
customStyles: {
backgroundColor: '#0891b2',
color: 'white',
padding: '24px',
borderRadius: '12px',
textAlign: 'center'
}
});
});
// ============================================
// SECTION 1: Visit Information
// ============================================
const visitInfo = form.addSubform('visitInfo', {
title: 'Visit Information',
customStyles: { backgroundColor: '#ecfeff', padding: '16px', borderRadius: '8px' }
});
visitInfo.addRow(row => {
row.addDropdown('visitType', {
label: 'Type of Visit',
options: [
{ id: 'hospital_inpatient', name: 'Hospital Stay (Inpatient)' },
{ id: 'hospital_outpatient', name: 'Hospital (Outpatient)' },
{ id: 'emergency', name: 'Emergency Room' },
{ id: 'clinic', name: 'Clinic/Doctor Office' },
{ id: 'urgent_care', name: 'Urgent Care' },
{ id: 'telehealth', name: 'Telehealth/Virtual' }
],
placeholder: 'Select visit type',
isRequired: true
}, '1fr');
row.addDropdown('department', {
label: 'Department/Specialty',
options: [
{ id: 'primary_care', name: 'Primary Care' },
{ id: 'cardiology', name: 'Cardiology' },
{ id: 'orthopedics', name: 'Orthopedics' },
{ id: 'pediatrics', name: 'Pediatrics' },
{ id: 'obgyn', name: 'OB/GYN' },
{ id: 'surgery', name: 'Surgery' },
{ id: 'oncology', name: 'Oncology' },
{ id: 'neurology', name: 'Neurology' },
{ id: 'other', name: 'Other' }
],
placeholder: 'Select department'
}, '1fr');
});
visitInfo.addRow(row => {
row.addDatepicker('visitDate', {
label: 'Date of Visit',
maxDate: new Date().toISOString()
}, '1fr');
row.addRadioButton('isFirstVisit', {
label: 'Is this your first visit with us?',
options: [
{ id: 'yes', name: 'Yes' },
{ id: 'no', name: 'No' }
],
orientation: 'horizontal'
}, '1fr');
});
// ============================================
// SECTION 2: Overall Experience
// ============================================
const overallSection = form.addSubform('overallSection', {
title: 'Overall Experience',
customStyles: { padding: '16px', borderRadius: '8px', border: '1px solid #e2e8f0' }
});
overallSection.addRow(row => {
row.addEmojiRating('overallMood', {
label: 'How would you rate your overall experience?',
preset: 'satisfaction',
size: 'lg',
showLabels: true,
alignment: 'center'
});
});
overallSection.addRow(row => {
row.addStarRating('overallRating', {
label: 'Overall Quality of Care',
maxStars: 5,
size: 'xl',
alignment: 'center',
showConfettiOnMax: true
});
});
// ============================================
// SECTION 3: Communication with Nurses
// ============================================
const nurseSection = form.addSubform('nurseSection', {
title: 'Nursing Care',
isVisible: () => {
const visitType = visitInfo.dropdown('visitType')?.value();
return visitType === 'hospital_inpatient' || visitType === 'hospital_outpatient' || visitType === 'emergency';
},
customStyles: { padding: '16px', borderRadius: '8px', backgroundColor: '#f0f9ff' }
});
nurseSection.addRow(row => {
row.addMatrixQuestion('nurseRatings', {
label: 'During your visit, how often did nurses...',
rows: [
{ id: 'courtesy', label: 'Treat you with courtesy and respect', isRequired: true },
{ id: 'listen', label: 'Listen carefully to you', isRequired: true },
{ id: 'explain', label: 'Explain things clearly', isRequired: true },
{ id: 'respond', label: 'Respond quickly when you needed help', isRequired: false },
{ id: 'pain', label: 'Address your pain or discomfort', isRequired: false }
],
columns: [
{ id: '1', label: 'Never' },
{ id: '2', label: 'Sometimes' },
{ id: '3', label: 'Usually' },
{ id: '4', label: 'Always' }
],
striped: true,
fullWidth: true
});
});
// ============================================
// SECTION 4: Communication with Doctors
// ============================================
const doctorSection = form.addSubform('doctorSection', {
title: 'Doctor/Provider Communication',
isVisible: () => overallSection.starRating('overallRating')?.value() !== null,
customStyles: { padding: '16px', borderRadius: '8px', backgroundColor: '#f0fdf4' }
});
doctorSection.addRow(row => {
row.addMatrixQuestion('doctorRatings', {
label: 'During your visit, how often did doctors/providers...',
rows: [
{ id: 'courtesy', label: 'Treat you with courtesy and respect', isRequired: true },
{ id: 'listen', label: 'Listen carefully to you', isRequired: true },
{ id: 'explain', label: 'Explain things in a way you could understand', isRequired: true },
{ id: 'time', label: 'Spend enough time with you', isRequired: false },
{ id: 'involve', label: 'Involve you in decisions about your care', isRequired: false }
],
columns: [
{ id: '1', label: 'Never' },
{ id: '2', label: 'Sometimes' },
{ id: '3', label: 'Usually' },
{ id: '4', label: 'Always' }
],
striped: true,
fullWidth: true
});
});
// ============================================
// SECTION 5: Staff Responsiveness
// ============================================
const staffSection = form.addSubform('staffSection', {
title: 'Staff & Responsiveness',
isVisible: () => overallSection.starRating('overallRating')?.value() !== null,
customStyles: { padding: '16px', borderRadius: '8px', border: '1px solid #e2e8f0' }
});
staffSection.addRow(row => {
row.addStarRating('receptionRating', {
label: 'Front Desk/Reception',
maxStars: 5,
size: 'md'
}, '1fr');
row.addStarRating('checkInRating', {
label: 'Check-in Process',
maxStars: 5,
size: 'md'
}, '1fr');
});
staffSection.addRow(row => {
row.addSlider('waitTimeMinutes', {
label: 'How long did you wait past your appointment time? (minutes)',
min: 0,
max: 90,
step: 5,
showValue: true,
unit: 'min'
});
});
staffSection.addRow(row => {
row.addRatingScale('waitTimeAcceptability', {
preset: 'likert-5',
label: 'The wait time was acceptable',
lowLabel: 'Strongly Disagree',
highLabel: 'Strongly Agree',
size: 'md'
});
});
// ============================================
// SECTION 6: Facility & Environment
// ============================================
const facilitySection = form.addSubform('facilitySection', {
title: 'Facility & Environment',
isVisible: () => {
const visitType = visitInfo.dropdown('visitType')?.value();
return visitType !== 'telehealth' && overallSection.starRating('overallRating')?.value() !== null;
},
customStyles: { padding: '16px', borderRadius: '8px', backgroundColor: '#faf5ff' }
});
facilitySection.addRow(row => {
row.addStarRating('cleanlinessRating', {
label: 'Cleanliness',
maxStars: 5,
size: 'md'
}, '1fr');
row.addStarRating('comfortRating', {
label: 'Comfort',
maxStars: 5,
size: 'md'
}, '1fr');
});
facilitySection.addRow(row => {
row.addStarRating('quietnessRating', {
label: 'Quietness/Noise Level',
maxStars: 5,
size: 'md',
tooltip: '5 stars = Very quiet and peaceful'
}, '1fr');
row.addStarRating('parkingRating', {
label: 'Parking/Accessibility',
maxStars: 5,
size: 'md'
}, '1fr');
});
// ============================================
// SECTION 7: Telehealth Experience (Conditional)
// ============================================
const telehealthSection = form.addSubform('telehealthSection', {
title: 'Telehealth Experience',
isVisible: () => visitInfo.dropdown('visitType')?.value() === 'telehealth',
customStyles: { padding: '16px', borderRadius: '8px', backgroundColor: '#eff6ff' }
});
telehealthSection.addRow(row => {
row.addStarRating('techEaseRating', {
label: 'Ease of Technology Use',
maxStars: 5,
size: 'md'
}, '1fr');
row.addStarRating('videoQualityRating', {
label: 'Video/Audio Quality',
maxStars: 5,
size: 'md'
}, '1fr');
});
telehealthSection.addRow(row => {
row.addThumbRating('wouldUseTelehealthAgain', {
label: 'Would you use telehealth again?',
showLabels: true,
upLabel: 'Yes, definitely',
downLabel: 'Prefer in-person',
alignment: 'left'
});
});
// ============================================
// SECTION 8: Discharge/After Care (For Hospital)
// ============================================
const dischargeSection = form.addSubform('dischargeSection', {
title: 'Discharge & Follow-up',
isVisible: () => {
const visitType = visitInfo.dropdown('visitType')?.value();
return (visitType === 'hospital_inpatient' || visitType === 'emergency') &&
overallSection.starRating('overallRating')?.value() !== null;
},
customStyles: { padding: '16px', borderRadius: '8px', border: '1px solid #e2e8f0' }
});
dischargeSection.addRow(row => {
row.addRatingScale('dischargeInstructions', {
preset: 'likert-5',
label: 'I clearly understood my discharge instructions',
lowLabel: 'Strongly Disagree',
highLabel: 'Strongly Agree',
size: 'md'
});
});
dischargeSection.addRow(row => {
row.addRatingScale('medicationExplained', {
preset: 'likert-5',
label: 'My medications were clearly explained',
lowLabel: 'Strongly Disagree',
highLabel: 'Strongly Agree',
size: 'md'
});
});
dischargeSection.addRow(row => {
row.addThumbRating('followUpScheduled', {
label: 'Was a follow-up appointment scheduled?',
showLabels: true,
upLabel: 'Yes',
downLabel: 'No',
alignment: 'left'
});
});
// ============================================
// SECTION 9: Issues/Concerns (Low Rating)
// ============================================
const issuesSection = form.addSubform('issuesSection', {
title: 'Help Us Improve',
isVisible: () => {
const rating = overallSection.starRating('overallRating')?.value();
return rating !== null && rating !== undefined && rating <= 2;
},
customStyles: { padding: '16px', borderRadius: '8px', backgroundColor: '#fef2f2', borderLeft: '4px solid #ef4444' }
});
issuesSection.addRow(row => {
row.addCheckboxList('concernAreas', {
label: 'What areas need improvement?',
options: [
{ id: 'wait_time', name: 'Wait time too long' },
{ id: 'communication', name: 'Poor communication' },
{ id: 'staff_attitude', name: 'Staff attitude/bedside manner' },
{ id: 'pain_management', name: 'Pain not adequately managed' },
{ id: 'cleanliness', name: 'Cleanliness issues' },
{ id: 'billing', name: 'Billing/insurance confusion' },
{ id: 'coordination', name: 'Care coordination problems' },
{ id: 'other', name: 'Other' }
],
orientation: 'vertical'
});
});
issuesSection.addRow(row => {
row.addTextarea('concernDetails', {
label: 'Please share more details',
placeholder: 'Your feedback helps us improve care for all patients...',
rows: 3,
autoExpand: true,
isRequired: () => {
const concerns = issuesSection.checkboxList('concernAreas')?.value() || [];
return concerns.length > 0;
}
});
});
// ============================================
// SECTION 10: Positive Feedback (High Rating)
// ============================================
const positiveSection = form.addSubform('positiveSection', {
title: 'Thank You!',
isVisible: () => {
const rating = overallSection.starRating('overallRating')?.value();
return rating !== null && rating !== undefined && rating >= 4;
},
customStyles: { padding: '16px', borderRadius: '8px', backgroundColor: '#ecfdf5', borderLeft: '4px solid #10b981' }
});
positiveSection.addRow(row => {
row.addSuggestionChips('excellenceAreas', {
label: 'What made your experience excellent?',
suggestions: [
{ id: 'caring_staff', name: 'Caring Staff' },
{ id: 'clear_communication', name: 'Clear Communication' },
{ id: 'short_wait', name: 'Short Wait' },
{ id: 'clean_facility', name: 'Clean Facility' },
{ id: 'thorough_exam', name: 'Thorough Examination' },
{ id: 'pain_managed', name: 'Pain Well Managed' },
{ id: 'felt_heard', name: 'Felt Heard' },
{ id: 'good_outcome', name: 'Good Outcome' }
],
max: 4,
alignment: 'center'
});
});
positiveSection.addRow(row => {
row.addTextarea('staffRecognition', {
label: 'Would you like to recognize any staff member?',
placeholder: 'Let us know who made a difference in your care...',
rows: 2,
autoExpand: true
});
});
// ============================================
// SECTION 11: Recommendation
// ============================================
const recommendSection = form.addSubform('recommendSection', {
title: 'Would You Recommend Us?',
isVisible: () => overallSection.starRating('overallRating')?.value() !== null,
customStyles: () => {
const nps = recommendSection.ratingScale('npsScore')?.npsCategory();
if (nps === 'promoter') return { backgroundColor: '#d1fae5', padding: '16px', borderRadius: '8px' };
if (nps === 'passive') return { backgroundColor: '#fef3c7', padding: '16px', borderRadius: '8px' };
if (nps === 'detractor') return { backgroundColor: '#fee2e2', padding: '16px', borderRadius: '8px' };
return { padding: '16px', borderRadius: '8px', border: '1px dashed #cbd5e1' };
}
});
recommendSection.addRow(row => {
row.addRatingScale('npsScore', {
preset: 'nps',
label: 'How likely are you to recommend our facility to friends or family?',
showCategoryLabel: true,
showSegmentColors: true,
showConfettiOnPromoter: true
});
});
// ============================================
// SECTION 12: Contact
// ============================================
const contactSection = form.addSubform('contactSection', {
title: 'Contact Information',
isVisible: () => overallSection.starRating('overallRating')?.value() !== null
});
contactSection.addRow(row => {
row.addTextarea('additionalComments', {
label: 'Any additional comments or suggestions?',
placeholder: 'We value all feedback...',
rows: 3,
autoExpand: true
});
});
contactSection.addRow(row => {
row.addCheckbox('allowContact', {
label: 'You may contact me to discuss my feedback'
});
});
contactSection.addRow(row => {
row.addEmail('contactEmail', {
label: 'Email Address',
placeholder: 'your@email.com',
isVisible: () => contactSection.checkbox('allowContact')?.value() === true,
isRequired: () => contactSection.checkbox('allowContact')?.value() === true
});
});
// ============================================
// SUMMARY SECTION
// ============================================
const summarySection = form.addSubform('summarySection', {
title: 'Your Feedback Summary',
isVisible: () => overallSection.starRating('overallRating')?.value() !== null
});
summarySection.addRow(row => {
row.addTextPanel('summaryContent', {
computedValue: () => {
const overall = overallSection.starRating('overallRating')?.value();
const visitType = visitInfo.dropdown('visitType')?.value();
const nps = recommendSection.ratingScale('npsScore')?.value();
const npsCategory = recommendSection.ratingScale('npsScore')?.npsCategory();
const excellence = positiveSection.suggestionChips('excellenceAreas')?.value() || [];
const concerns = issuesSection.checkboxList('concernAreas')?.value() || [];
if (overall === null || overall === undefined) return '';
let emoji = overall >= 4 ? '💚' : overall >= 3 ? '💛' : '❤️🩹';
let summary = `${emoji} Patient Feedback Summary\n`;
summary += `${'═'.repeat(28)}\n\n`;
summary += `⭐ Care Rating: ${overall}/5 stars\n`;
const visitLabels: Record<string, string> = {
'hospital_inpatient': 'Hospital Stay',
'hospital_outpatient': 'Outpatient Visit',
'emergency': 'Emergency Visit',
'clinic': 'Clinic Visit',
'urgent_care': 'Urgent Care',
'telehealth': 'Telehealth'
};
if (visitType) {
summary += `🏥 Visit Type: ${visitLabels[visitType] || visitType}\n`;
}
if (nps !== null && nps !== undefined) {
summary += `\n📊 Recommendation: ${nps}/10`;
if (npsCategory) {
summary += ` (${npsCategory.charAt(0).toUpperCase()}${npsCategory.slice(1)})`;
}
}
if (excellence.length > 0) {
summary += `\n\n✨ Excellence areas: ${excellence.length} noted`;
}
if (concerns.length > 0) {
summary += `\n⚠️ Concerns: ${concerns.length} flagged`;
}
return summary;
},
customStyles: () => {
const rating = overallSection.starRating('overallRating')?.value();
const baseStyles = {
padding: '16px',
borderRadius: '8px',
whiteSpace: 'pre-wrap',
fontFamily: 'monospace',
fontSize: '14px'
};
if (rating !== null && rating !== undefined && rating >= 4) {
return { ...baseStyles, backgroundColor: '#d1fae5', borderLeft: '4px solid #10b981' };
} else if (rating !== null && rating !== undefined && rating >= 3) {
return { ...baseStyles, backgroundColor: '#fef3c7', borderLeft: '4px solid #f59e0b' };
} else if (rating !== null && rating !== undefined) {
return { ...baseStyles, backgroundColor: '#fee2e2', borderLeft: '4px solid #ef4444' };
}
return baseStyles;
}
});
});
// ============================================
// FORM CONFIGURATION
// ============================================
form.configureSubmitButton({
label: 'Submit Feedback',
isVisible: () => overallSection.starRating('overallRating')?.value() !== null
});
form.configureCompletionScreen({
type: 'text',
title: 'Thank You for Your Feedback!',
message: 'Your response helps us improve the quality of care we provide. We are committed to delivering the best possible patient experience.'
});
}
Frequently Asked Questions
Is this survey HIPAA compliant?
The survey template itself does not collect Protected Health Information (PHI). However, you should ensure your hosting and data storage comply with HIPAA requirements. Consider using a HIPAA-compliant form hosting service if collecting alongside patient identifiers.
How does this compare to official HCAHPS?
This template is inspired by HCAHPS methodology but is not an official CMS survey. It covers similar domains (communication, responsiveness, environment) and uses comparable rating scales. For official HCAHPS submission, you must use CMS-approved vendors.
When should I send the patient satisfaction survey?
Best practice is 24-48 hours after discharge for hospital stays, or immediately after outpatient visits. For ongoing care, quarterly touchpoints work well. Avoid surveying during acute illness phases.
What response rate should I expect?
Healthcare surveys typically see 20-35% response rates via email. SMS can achieve 30-40%. In-person tablet surveys at checkout can reach 50-60%. Higher rates come with staff encouragement and short survey length.
Can I customize the rating scales?
Yes, the form uses standard 5-point scales (Never/Sometimes/Usually/Always) which are evidence-based for healthcare. You can modify labels while keeping the scale structure for benchmarking purposes.
How do I act on negative feedback?
The form flags low ratings with automatic follow-up questions. Implement a service recovery process: contact dissatisfied patients within 24 hours, document concerns, and close the loop. Track trends to identify systemic issues.