NAME : RATING
1. Poor
IP. NO.: CONSULTANT NAME 2. Average
BED NO.: DOA : DOD : 3. Good
4. V Good
CONTACT NO. : REFERRED BY : 5. Excellent
1. FRONT OFFICE / i!zaV vkWi!hl 1 2 3 4 5 5. MAINTENANCE / esUVsuUl
a. Polite, Friendly and helpful / fouez vkSj lgk;d a. Effectiveness of Air Condition 1 2 3 4 5
b. Explanation of admission procedure, Room, Facility & Tarriff ,vj daMh'kuj dh izHkkof'kyrk
izos'k izfdz;k] :e] brj lsok,s vkSj VWjhi! dk Li"Vhdj.k b. Telephone / Vsyhi!ksu
c. Lighting / ykbZV~l
2. NURSING / uflZx
a d. Television / VhOgh
a. Receiving you on a admission / vkidks izos'k izkIr djuk gS
b. Response / Attentiveness to your queries :
vkids iz'uks dk tokc @ izfrdzh;k nsuk 6. DIETARY / vkgkj
c. Timely Medication / le; ij nok a. Food quality and taste
d. Clarity in communication / ckr djus es Li"Vrk Hkkstu dh xq.koRrk vkSj Lokn
b. On time service / le; ij lsok
3. HOUSEKEEPING / gkmlfdihax c. Diet Counseling / vkgkj ijke'kZ
a. Daily cleaning of Room / Toilet
:e vkSj 'kkSpky; dh li!kbZ 7. DISCHARGE / fuoZgu
b. Prompt service delivery / lsok rRdky nsuk
a. Clear instruction for medication
c. Polite, Friendly and helpful / fouez vkSj lgk;d
nok ds fy, Li"V funsZ'k
4. DOCTORS : b. Time taken for discharge
a. Proper Explanation of condition and treatment fuoZgu ds fy, fy;k x;k le;
chekjh vkSj mipkj dk mfpr Li"Vhdj.k 8. BILLING / fcyhax
b. Courteous and concerned a. Explanation and clarification of
chekjh vkSj mipkj doubts (Counselling)
c. Counseling of approximate cost of treatment 'kadkvks dk Li"Vhdj.k vkSj
mipkj dh vuqekfur ykxr dk ijke'kZ ikjnf'kZrk es ijke'kZ
b. Time taken for billing
fcyhax ds fy, fy;k x;k le;
a : WILL YOU RECOMMEND OUR HOSPITAL TO YOUR FRIENDS / RELATIVES YES NO
D;k vki vius nksLrks ;k fj'rsnkjkas ls gekjs vLirky fd fli!kjh'k djsaxs A gkWa uk
A) ANY INCONVENIENCES FACED / fdlh Hkh rjg fd vlqfo/kk,a
B) ANY SUGGESTIONS TO IMPROVE OUR HOSPITAL / gekjs vLirky esa lq/kkj djus ds fy, dksbZ lq>ko A
PATIENT SIGNATURE / RELATIVE SIGNATURE / Lok{kjh DATE / fnukad
ADDRESS / irk
SSH/QID/V1/10
