QuestionPunkQuestionPunk
無料で始める
すべてのテンプレート
Healthcare & Clinical

Hospital Discharge Experience & Readiness Survey

Assesses whether patients left the hospital genuinely prepared to manage recovery at home — covering instruction clarity, medication confidence, and follow-up care arrangements. An AI follow-up interview digs into what actually happened after discharge, especially for patients who needed unplanned care, to surface where the handoff broke down.

このテンプレートを使うほかのテンプレートを見る

設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全12問・約7分
Q01
メッセージ

Thanks for taking a few minutes to tell us about your recent hospital discharge. Your honest answers help us make the transition home safer and clearer for future patients. Your responses are completely confidential and anonymized. This takes about 4-5 minutes.

Q02
選択式必須

What was the primary reason for your hospital stay?

  • Planned surgery or procedure
  • Emergency or urgent treatment
  • Childbirth
  • Ongoing condition management
Q03
選択式必須

How long ago were you discharged?

  • Today or yesterday
  • 2-7 days ago
  • 1-4 weeks ago
  • More than a month ago
Q04
オピニオンスケール必須

Overall, how prepared did you feel to leave the hospital and manage your recovery at home?

スケール: 1 – 10
最小:Not at all prepared最大:Completely prepared
Q05
マトリクス必須

Before you left the hospital, how clearly were each of these covered?

4行 × 3列
  • Instructions for taking my medications
  • Warning signs that mean I should seek help
  • When and how to schedule follow-up care
  • Who to contact if I have questions after leaving
列: Not covered · Covered but unclear · Covered and clear
Q06
選択式必須

Did hospital staff arrange a follow-up appointment with a doctor before you left?

  • Yes, it was scheduled for me before I left
  • Yes, but I had to schedule it myself afterward
  • No appointment was arranged
  • Not sure
Q07
選択式必須

Since leaving the hospital, have you contacted your doctor's office, gone to urgent care, or returned to the emergency room because something about your discharge care was unclear or didn't go as planned?

  • No, everything went as expected
  • Yes, I contacted my doctor's office
  • Yes, I went to urgent care
  • Yes, I returned to the emergency room
Q08
評価スケール

How would you rate the courtesy and respect shown by the staff who handled your discharge?

範囲: 1 – 5
最小:Poor最大:Excellent
Q09
AIインタビュー

Reconstruct what actually happened after this patient left the hospital, anchoring on their preparedness rating and any items they marked 'unclear' or 'not covered' in the instructions breakdown. If they contacted a doctor, went to urgent care, or returned to the ER, get the specific sequence: what confused them, what they wish had been explained differently, and whether it was preventable with clearer discharge instructions. If they felt fully prepared, ask what specifically made the handoff work well.

Q10
選択式

What is your age range?

  • Under 30
  • 30-44
  • 45-59
  • 60-74
  • 75 or older
  • Prefer not to say
Q11
選択式

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q12
メッセージ

Thank you for sharing your discharge experience. Your responses will be reviewed by our care team to identify where discharge instructions and follow-up planning can be made clearer and safer for future patients.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Goes beyond a static checklist by using an AI follow-up interview to reconstruct what actually happened after discharge, especially for patients who needed unplanned care, surfacing exactly where the handoff broke down
  • Combines structured measures (opinion scale on preparedness, a matrix on clarity of pre-discharge instructions, ratings of staff courtesy) with open-ended probing rather than relying on multiple choice alone
  • Directly links discharge process gaps to real-world outcomes by asking whether a follow-up appointment was arranged and whether the patient later needed a doctor, urgent care, or ER visit
  • Produces an automated report from the responses with transparent, reviewable AI prompts, rather than leaving analysis to manual chart review

Jotform

Hospital Discharge Form Template

A static, fillable discharge form built on Jotform's general form builder, aimed at capturing discharge documentation rather than probing patient experience in depth. It's a ready-to-use template but structurally a form, not an interview-style survey. Customization is drag-and-drop with no adaptive questioning.

優れている点

  • Quick to deploy and customize using Jotform's widely-used form builder
  • Familiar drag-and-drop interface for editing fields
  • Likely supports standard form logic and integrations typical of Jotform templates

物足りない点

  • Static field-based form with no adaptive AI follow-up to probe individual patient answers
  • No mechanism to dig into what happened after discharge for patients who needed unplanned care
  • No published methodology or prompt transparency since it isn't an AI-driven interview tool

SurveySparrow

Free Hospital Discharge Form Template

A conversational-style survey template from SurveySparrow's healthcare template library, offered free. It focuses on chat-like question flow but is still a fixed question set rather than a true adaptive interview. Good for basic discharge feedback collection at no cost.

優れている点

  • Conversational UI that can feel more engaging than a plain form
  • Free to use, lowering the barrier to start collecting feedback
  • Part of a broader healthcare template library for related surveys

物足りない点

  • No adaptive AI follow-up interview to explore individual patient circumstances beyond preset questions
  • No automated quality scoring of individual responses
  • No voice AI interview option for patients who prefer speaking over typing

Typeform

Hospital Discharge Form Template

A polished, one-question-at-a-time template on Typeform's design-forward platform, well suited for simple discharge data collection. It relies on fixed question logic rather than any AI-driven probing of open-ended answers. Reporting is limited to Typeform's standard response summaries.

優れている点

  • Clean, mobile-friendly one-question-at-a-time design
  • Easy for patients to complete quickly
  • Supports basic conditional logic between questions

物足りない点

  • No adaptive AI interview to reconstruct what happened post-discharge for patients needing unplanned care
  • No automated per-response quality scoring
  • No guided screen-share task capability, which isn't relevant to this use case but underscores it's a plain survey tool

QuestionPro

Patient Satisfaction Survey Questions + Sample Questionnaire Template

A general hospital patient satisfaction template rather than one built specifically around discharge readiness, so coverage of instruction clarity, medication confidence, and follow-up-care arrangements would need to be added manually. It's a solid broad satisfaction questionnaire from an established survey platform, useful as a starting reference rather than a discharge-specific tool.

優れている点

  • Broad, established patient satisfaction question bank covering multiple touchpoints
  • Backed by a mature survey platform with standard reporting and analytics
  • Easy to adapt sample questions for various hospital departments

物足りない点

  • Not specifically designed around discharge readiness or post-discharge outcomes
  • No adaptive AI follow-up interview to surface where a discharge handoff broke down
  • No transparent, reviewable AI prompt methodology since it's a static questionnaire

よくあるご質問

「Hospital Discharge Experience & Readiness Survey」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が12問含まれており、最初の設問は次のとおりです：「Thanks for taking a few minutes to tell us about your recent hospital discharge. Your honest answers help us make the tr…」・「What was the primary reason for your hospital stay?」・「How long ago were you discharged?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、12問を約7分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

関連テンプレート

似たテーマのほかの調査もご覧ください。

すべて見る
Healthcare & Clinical

Family Medical History & Personal Risk Awareness Survey

Captures which health conditions run in a patient's family, which relatives are affected, and how concerned the patient is about their own risk. Built for primary care, genetic counseling, or preventive health intake. An AI follow-up interview digs into the single most concerning condition — who had it, how severe, and whether it has already changed the patient's screening or lifestyle habits.

テンプレートを見る
Healthcare & Clinical

Patient Discharge & Medical Release Experience Survey

Captures how clearly patients understood their discharge instructions, medications, and follow-up care after being released from a hospital, ER, or outpatient procedure. An AI follow-up interview digs into the specific point where instructions were unclear, so care teams can fix the discharge process before it causes a readmission or complication.

テンプレートを見る
Healthcare & Clinical

Patient Experience of Nursing Care Assessment

Captures how patients or clients experienced the nursing care they received — communication, responsiveness, pain management, and discharge preparation — for hospitals, clinics, and home health teams. An AI follow-up interview reconstructs the specific moment that most shaped their overall rating, surfacing concrete coaching moments beyond a satisfaction score.

テンプレートを見る
Healthcare & Clinical

Patient Referral Experience & Handoff Survey

Tracks how smoothly patients move from being referred to actually being seen by a specialist — scheduling ease, clarity of instructions, and communication between providers — with an AI follow-up that pinpoints exactly where the handoff broke down or worked well. Built for practice managers and care coordination teams.

テンプレートを見る
Healthcare & Clinical

Graduation Exit Survey: Satisfaction & Career Readiness

Captures graduating students' satisfaction with their program, how prepared they feel for their next step, and where the institution should invest next — built for registrars, program directors, and career services teams closing out a cohort. An AI follow-up interview digs into the real reasons behind low preparedness or satisfaction scores instead of stopping at a number.

テンプレートを見る
Healthcare & Clinical

Nursing Home Resident Satisfaction Survey

Captures how residents and their families experience daily care, staff responsiveness, meals, activities, and communication in a nursing home or assisted living community. An AI follow-up interview digs into the story behind the lowest-rated experience so administrators know exactly what to fix first, not just where the score dropped.

テンプレートを見る