Q01
Message
All templates
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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
What type of visit or stay best describes your care?
- Inpatient hospital stay
- Outpatient clinic visit
- Emergency department visit
- Home health visit
- Other
Q03
Opinion ScaleRequired
Based on this visit or stay, how likely are you to recommend our nursing team's care to family or friends?
Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q04
MatrixRequired
Thinking about the nurses who cared for you, how often did each of the following happen?
5 rows × 4 columns
- Nurses listened carefully to my questions and concerns
- Nurses explained things in a way I could understand
- Nurses treated me with courtesy and respect
- Nurses responded to my call button or requests within a reasonable time
- Nurses kept me informed about my care plan
Columns: Never · Sometimes · Usually · Always
Q05
Opinion Scale
If you experienced pain during this visit, how well did the nursing staff manage it?
Scale: 1 – 5
Min:Not managed well at allMax:Managed extremely well
Q06
Rating ScaleRequired
How clear were the instructions nurses gave you about medications or home care before you left?
Range: 1 – 5
Min:Very unclearMax:Very clear
Q07
AI Interview
Reconstruct the specific moment during this visit that most shaped the respondent's overall recommendation rating: what happened, which shift or moment it was, and exactly what a nurse said or did (or failed to do). If the rating was low, identify the single most important lapse in communication, responsiveness, or pain management, and ask what would have changed it. If the rating was high, pin down the specific action or nurse behavior that stood out so it can be reinforced as a best practice.
Q08
Ranking
Rank these aspects of nursing care from most to least important to you personally.
- Clear communication and listening
- Effective pain management
- Quick response to call button or requests
- Clear explanation of medications and procedures
- Emotional support and compassion
- Coordination between nurses and doctors
Drag to rank
Q09
Multiple Choice
During this visit, how often did you wait longer than expected for a nurse to respond to your call button or requests?
- Never
- Once
- A few times
- Many times
- Not applicable
Q10
Long Text
Is there anything a nurse did especially well, or anything they could improve, that we haven't asked about?
Q11
Multiple Choice
Which age range best describes you?
- Under 18
- 18-29
- 30-44
- 45-59
- 60-74
- 75 or older
- Prefer not to say
Q12
Multiple Choice
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q13
Message
Thank you for sharing your experience! Your responses will be reviewed by the nursing leadership team to recognize great care and identify where we can do better.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Includes a dedicated AI follow-up interview that reconstructs the specific moment during the visit that most shaped the patient's overall rating, turning a single score into a concrete coaching moment.
- Covers the full experience arc patients actually care about: nurse responsiveness (wait-times question), communication frequency (matrix on nurse behaviors), pain management effectiveness, and clarity of discharge/medication instructions.
- Uses a ranking question to reveal which aspects of nursing care (e.g., communication, pain control, promptness) each respondent personally values most, not just how they rated the visit.
- Closes with a transparent note that responses are reviewed by the nursing leadership team, and results are compiled into an auto-generated report rather than left as raw export data.
Jotform
Hospice Nursing Assessment Form TemplateA fielding-ready form template aimed at hospice nursing assessment, built on Jotform's drag-and-drop form builder. It reads as a general clinical/intake assessment form rather than a purpose-built patient-experience survey, and like all Jotform templates it is a static question set with no adaptive interviewing layer.
What it does well
- Easy to customize fields and branding within Jotform's established form builder
- Can integrate with Jotform's broader ecosystem (e-signatures, tables, conditional logic)
- Likely offers a free tier for basic use
Where it falls short
- Static question list with no adaptive AI follow-up to probe why a rating was given
- No per-response quality scoring or automated coaching-moment extraction
- No voice AI interview option or transparent prompt methodology
Typeform
Nursing Assessment Form TemplateA conversational, one-question-at-a-time nursing assessment template built on Typeform's design-forward form engine. It's framed as a general nursing assessment tool rather than an experience/satisfaction survey specifically, and is a fixed set of questions with no follow-up logic beyond simple branching.
What it does well
- Polished, conversational UI that tends to improve completion rates
- Simple embedding and sharing across web and mobile
- Familiar builder for teams already using Typeform for other surveys
Where it falls short
- No adaptive AI interview to reconstruct the specific moment behind a rating
- No automated quality scoring or auto-generated analysis report
- No transparent, published prompt methodology behind any 'smart' logic
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.