Form CMS-10500 Outpatient and Ambulatory Surgery Experience of Care Sur

Outpatient and Ambulatory Surgery Experience of Care Survey (CMS-10500)

Outpatient and Ambulatory Surgery Experience of Care Survey_Draft_to_OMB_post_60-day_notice_revisions [rev 12-27-13 by OSORA PRA

Outpatient and Ambulatory Surgery Experience of Care Survey

OMB: 0938-1240

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Outpatient and Ambulatory Surgery
Experience of Care Survey



<Date>

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-New. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Survey Instructions

Answer all the questions by checking the box to the left of your answer.

You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

Yes

No If No, go to #1.

This survey asks about your experience at the facility named in the cover letter. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure.

Please answer these questions only for the date included in the cover letter. Do not include any other procedures in your answers.

I. Before Your Procedure

The first few questions are about getting ready for your procedure.

  1. Did your doctor or anyone from the facility give you all the information you needed about your procedure?

  1. Shape1 Yes, definitely

  1. Shape2 Yes, somewhat

  2. Shape3 No

  1. Did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?

  1. Shape4 Yes, definitely

  1. Shape5 Yes, somewhat

  2. Shape6 No

  1. When you arrived at this facility on the day of your procedure, did the check-in process run smoothly?

  1. Shape7 Yes, definitely

  1. Shape8 Yes, somewhat

  2. Shape9 No

  1. Did you have a delay in your scheduled procedure?

  1. Shape10 Yes

  1. Shape11 No If No, go to #6

  1. Did anyone from the facility keep you informed about the delay?

  1. Shape12 Yes

  1. Shape13 No

II. About the Facility and Staff

  1. Was the facility clean?

  1. Shape14 Yes, definitely

  1. Shape15 Yes, somewhat

  2. Shape16 No

  1. When you talked with the staff about your procedure, were you able to talk in an area that was private?

  1. Shape17 Yes, definitely

  1. Shape18 Yes, somewhat

  2. Shape19 No

  1. Were the clerks and receptionists at the facility as helpful as you thought they should be?

  1. Shape20 Yes, definitely

  1. Shape21 Yes, somewhat

  2. Shape22 No

  1. Did the clerks and receptionists at the facility treat you with courtesy and respect?

  1. Shape23 Yes, definitely

  1. Shape24 Yes, somewhat

  2. Shape25 No

  1. Did the doctors, nurses and other staff treat you with courtesy and respect?

  1. Shape26 Yes, definitely

  1. Shape27 Yes, somewhat

  2. Shape28 No

  1. Did the doctors, nurses and other staff make sure you were as comfortable as possible?

  1. Shape29 Yes, definitely

  1. Shape30 Yes, somewhat

  2. Shape31 No

III. Communications About your Procedure

  1. Did you have any questions for the doctors, nurses or other staff?

  1. Shape32 Yes

  1. Shape33 No If No, go to #14

  1. Did the doctors, nurses and other staff answer your questions?

  1. Shape34 Yes, definitely

  1. Shape35 Yes, somewhat

  2. Shape36 No

  1. Did the doctors, nurses and other staff explain things in a way that was easy for you to understand?

  1. Shape37 Yes, definitely

  1. Shape38 Yes, somewhat

  2. Shape39 No

  1. Did you get conflicting information about your care from the doctors, nurses or other staff at the facility?

  1. Shape40 Yes, definitely

  1. Shape41 Yes, somewhat

  2. Shape42 No

  1. Anesthesia is something that would make you go to sleep or not feel pain during your procedure. Were you given anesthesia?

  1. Shape43 Yes

  1. Shape44 No If No, go to #19

  1. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand?

  1. Shape45 Yes

  1. Shape46 No

  1. Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand?

  1. Shape47 Yes

  1. Shape48 No

  1. Discharge instructions include things like symptoms you should watch for after your procedure, instructions about medicines, and home care. Before you left the facility, did you receive written discharge instructions?

  1. Shape49 Yes

  1. Shape50 No

  1. Did your doctor or anyone from the facility ask if you had someone to help you get home after your procedure?

  1. Shape51 Yes

  1. Shape52 No

IV. Your Recovery

  1. Did your doctor or anyone from the facility prepare you for what to expect during your recovery?

  1. Shape53 Yes, definitely

  1. Shape54 Yes, somewhat

  2. Shape55 No

  1. Ways to control pain can include prescription medicine, over-the-counter pain relievers or ice packs, for example. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure?

  1. Shape56 Yes

  1. Shape57 No

  1. At any time after leaving the facility, did you have pain as a result of your procedure?

  1. Shape58 Yes

  1. Shape59 No If No, go to #25

  1. After you left the facility, did you get medical care because of pain as a result of your procedure?

  1. Shape60 Yes

  1. Shape61 No

  1. Before you left, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting?

  1. Shape62 Yes

  1. Shape63 No

  1. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?

  1. Shape64 Yes

  1. Shape65 No If No, go to #28

  1. After you left the facility, did you get medical care because of the nausea or vomiting as a result of your procedure or the anesthesia?

  1. Shape66 Yes

  1. Shape67 No

  1. Before you left, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure?

  1. Shape68 Yes

  1. Shape69 No

  1. At any time after leaving the facility, did you have bleeding as a result of your procedure?

  1. Shape70 Yes

  1. Shape71 No If No, go to #31

  1. After you left the facility, did you get medical care because of bleeding as a result of your procedure?

  1. Shape72 Yes

  1. Shape73 No

  1. Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection?

  1. Shape74 Yes

  1. Shape75 No

  1. At any time after leaving the facility, did you have any signs of infection?

  1. Shape76 Yes

  1. Shape77 No If No, go to #34

  1. After you left the facility, did you get medical care because of signs of infection as a result of your procedure?

  1. Shape78 Yes

  1. Shape79 No

  1. After you left the facility, did your doctor or anyone from the facility contact you to see how you were recovering?

  1. Shape80 Yes

  1. Shape81 No

V. Your Overall Experience

  1. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?

Shape82 0 = Worst facility possible

Shape83 1

Shape84 2

Shape85 3

Shape86 4

Shape87 5

Shape88 6

Shape89 7

Shape90 8

Shape91 9

Shape92 10 = Best facility possible

  1. Would you recommend this facility to your friends and family?

  1. Shape93 Definitely no

  1. Shape94 Probably no

  2. Shape95 Probably yes

  3. Shape96 Definitely yes

VI. About You

  1. In general, how would you rate your overall health?

  1. Shape97 Excellent

  1. Shape98 Very good

  2. Shape99 Good

  3. Shape100 Fair

  4. Shape101 Poor

  1. In general, how would you rate your overall mental or emotional health?

  1. Shape102 Excellent

  1. Shape103 Very good

  2. Shape104 Good

  3. Shape105 Fair

  4. Shape106 Poor

  1. What is your age?

  1. Shape107 18 to 24

  1. Shape108 25 to 34

  2. Shape109 35 to 44

  3. Shape110 45 to 54

  4. Shape111 55 to 64

  5. Shape112 65 to 74

  6. Shape113 75 to 79

  7. Shape114 80 to 84

  8. Shape115 85 or older

  1. Are you male or female?

  1. Shape116 Male

  1. Shape117 Female

  1. What is the highest grade or level of school that you have completed?

  1. Shape118 8th grade or less

  1. Shape119 Some high school, but did not graduate

  2. Shape120 High school graduate or GED

  3. Shape121 Some college or 2-year degree

  4. Shape122 4-year college graduate

  5. Shape123 More than 4-year college degree

  1. Are you Hispanic, Latino/a, or Spanish origin?

  1. Shape124 Yes, Hispanic, Latino/a, or Spanish

  1. Shape125 No, not Hispanic, Latino/a, or Spanish If No, go to #44

  1. Which group best describes you?

  1. Shape126 Mexican, Mexican American, Chicano/a

  1. Shape127 Puerto Rican

  2. Shape128 Cuban

  3. Shape129 Another Hispanic, Latino/a, or Spanish origin

  1. What is your race? You may select one or more categories.

  1. Shape130 White

  1. Shape131 Black or African American

  2. Shape132 American Indian or Alaska Native

  3. Shape133 Asian Indian

  4. Shape134 Chinese

  5. Shape135 Filipino

  6. Shape136 Japanese

  7. Shape137 Korean

  8. Shape138 Vietnamese

  9. Shape139 Other Asian

  10. Shape140 Native Hawaiian

  11. Shape141 Guamanian or Chamorro

  12. Shape142 Samoan

  13. Shape143 Other Pacific Islander

  1. How well do you speak English?

  1. Shape144 Very well

  1. Shape145 Well

  2. Shape146 Not well

  3. Shape147 Not at all

  1. Do you speak a language other than English at home?

  1. Shape148 Yes

  1. Shape149 No If No, go to #48

  1. What is that language?

  1. Shape150 Spanish

  1. Shape151 Other Language (PLEASE SPECIFY):

(Please print.)

  1. Did someone help you complete this survey?

  1. Shape152 Yes

  1. Shape153 No If No, go to END.

  1. How did that person help you? Check all that apply.

  1. Shape154 Read the questions to me

  1. Shape155 Wrote down the answers I gave

  2. Shape156 Answered the questions for me

  3. Shape157 Translated the questions into my language

  4. Shape158 Helped in some other way: (EXPLAIN):

(Please print.)

  1. Shape159 No one helped me complete this survey

END

When you have completed the survey, please mail it in the postage-paid envelope provided.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleProtocols and Guidelines Manual
SubjectHome Health Care CAHPS Survey
AuthorCenters for Medicare & Medicaid Services
File Modified0000-00-00
File Created2021-01-28
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