Q01
メッセージ
すべてのテンプレート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.
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11問・約6分
Q02
選択式必須
What type of specialist or service were you referred to? (Template note: replace with the specialty list most relevant to your practice.)
- Cardiology
- Orthopedics
- Dermatology
- Physical Therapy
- Imaging or Diagnostic Testing
- Mental or Behavioral Health
- Other specialist
Q03
選択式必須
How much time passed between your referral being made and your specialist appointment actually happening (or being scheduled)?
- Less than 1 week
- 1-2 weeks
- 3-4 weeks
- More than a month
- I still haven't been able to schedule it
Q04
オピニオンスケール必須
How clear were the instructions you received about next steps after your referral (e.g., who to call, what forms or authorizations were needed)?
スケール: 1 – 5
最小:Not at all clear最大:Extremely clear
Q05
マトリクス必須
Please rate each part of your referral experience.
4行 × 5列
- Ease of scheduling the specialist appointment
- Communication between your primary provider and the specialist's office
- Amount of information you received about why you were referred
- Wait time between the referral and your appointment
列: Poor · Fair · Good · Very good · Excellent
Q06
選択式必須
Did you complete the appointment you were referred to?
- Yes, I completed it
- Not yet, but it's scheduled
- No, I decided not to go
- No, I couldn't get an appointment
Q07
評価スケール必須
Overall, how would you rate your experience with the referral process from start to finish?
範囲: 1 – 5
最小:Very poor最大:Excellent
Q08
AIインタビュー
For respondents whose referral was delayed, incomplete, or rated poorly, reconstruct the specific breakdown: was it the referral paperwork, insurance authorization, scheduling with the specialist's office, or unclear instructions from their own provider. Anchor on the exact point in the process where things went wrong and what would have fixed it. If the referral went smoothly, probe what specifically made the handoff between providers feel seamless so it can be replicated for other patients.
Q09
オピニオンスケール
Based on how your referral was handled, how likely are you to recommend this practice to friends or family?
スケール: 0 – 10
最小:Not at all likely最大:Extremely likely
Q10
選択式
Which age group do you fall into?
- Under 18
- 18-34
- 35-49
- 50-64
- 65 or older
Q11
メッセージ
That's everything — thank you! Your answers will be reviewed by our care coordination team to identify where referral handoffs can be made faster and clearer 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
- Includes an AI follow-up interview that automatically triggers for respondents whose referral was delayed, incomplete, or rated poorly, and probes to reconstruct exactly where the handoff broke down or worked well — something a static form can't do.
- Uses a matrix question to rate distinct parts of the referral journey (scheduling, instructions, communication) alongside a separate overall experience rating, so practice managers see both granular and holistic views.
- Pairs objective process metrics (time between referral and appointment, completion status, clarity of instructions) with recommendation likelihood and demographic segmentation, then rolls it all into an auto-generated report.
- Opens and closes with conversational chat messages that set expectations and confirm care-coordination staff will review responses, which reads more like a guided conversation than a cold intake form.
Jotform
Patient Referral Form TemplateThis is a static intake-style form for capturing referral details (e.g., patient info, referring provider, specialist), not a post-referral experience/feedback survey. It's fielding-ready as a document-style form but doesn't measure how the handoff felt to the patient. Jotform's strength is broad customization and integrations rather than experience research.
優れている点
- Highly customizable drag-and-drop form builder
- Free tier available
- Wide range of integrations with EHR/CRM-adjacent tools
物足りない点
- No adaptive AI follow-up probing on delayed or poor-quality referrals
- No automated per-response quality scoring or synthesized report
- No transparent, publishable prompt/methodology for how responses are analyzed
SurveySparrow
Free Patient Referral Form Template | For Medical InstitutionsFramed as a referral intake form for medical institutions rather than a survey tracking the patient's referral-to-appointment experience. Its conversational, chat-like question flow is a genuine strength for completion rates, but it stops at data collection with no deeper diagnostic layer. Free to use, per the page.
優れている点
- Conversational, chat-style question flow
- Mobile-friendly design
- Free template offering
物足りない点
- No adaptive AI interview to pinpoint where a handoff broke down
- No automated quality scoring per response
- No auto-generated analysis report for care coordination teams
Typeform
Patient Referral Form TemplateAnother referral-intake-oriented template rather than a purpose-built patient experience/handoff survey. Typeform's polished, one-question-at-a-time interface is a genuine usability strength, but the template is a fixed question set with no dynamic branching into experience diagnostics. Good for basic intake, not for root-cause analysis of referral friction.
優れている点
- Polished, one-question-at-a-time interface with strong completion UX
- Easy visual customization
- Established brand familiarity among respondents
物足りない点
- Static question set with no adaptive AI follow-up for poorly-rated referrals
- No automated per-response quality scoring
- No voice AI interview option or auto-generated diagnostic report
よくあるご質問
「Patient Referral Experience & Handoff 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11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 share how your recent referral went. Your responses are completely confidential and a…」・「What type of specialist or service were you referred to? (Template note: replace with the specialty list most relevant t…」・「How much time passed between your referral being made and your specialist appointment actually happening (or being sched…」。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、11問を約6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。
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