Q01
Message
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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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
12 questions · ~7 min
Q02
Multiple ChoiceRequired
What was the primary reason for your hospital stay?
- Planned surgery or procedure
- Emergency or urgent treatment
- Childbirth
- Ongoing condition management
Q03
Multiple ChoiceRequired
How long ago were you discharged?
- Today or yesterday
- 2-7 days ago
- 1-4 weeks ago
- More than a month ago
Q04
Opinion ScaleRequired
Overall, how prepared did you feel to leave the hospital and manage your recovery at home?
Scale: 1 – 10
Min:Not at all preparedMax:Completely prepared
Q05
MatrixRequired
Before you left the hospital, how clearly were each of these covered?
4 rows × 3 columns
- 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
Columns: Not covered · Covered but unclear · Covered and clear
Q06
Multiple ChoiceRequired
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
Multiple ChoiceRequired
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
Rating Scale
How would you rate the courtesy and respect shown by the staff who handled your discharge?
Range: 1 – 5
Min:PoorMax:Excellent
Q09
AI Interview
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
Multiple Choice
What is your age range?
- Under 30
- 30-44
- 45-59
- 60-74
- 75 or older
- Prefer not to say
Q11
Multiple Choice
What is your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q12
Message
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.
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
- 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 TemplateA 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.
What it does well
- 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
Where it falls short
- 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 TemplateA 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.
What it does well
- 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
Where it falls short
- 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 TemplateA 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.
What it does well
- Clean, mobile-friendly one-question-at-a-time design
- Easy for patients to complete quickly
- Supports basic conditional logic between questions
Where it falls short
- 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 TemplateA 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.
What it does well
- 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
Where it falls short
- 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
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.