Q01
Message
All templatesHealthcare & 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.
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 were you discharged from?
- Emergency room
- Inpatient hospital stay
- Outpatient surgery or procedure
- Urgent care
- Other
Q03
Multiple ChoiceRequired
Did you receive written discharge instructions before you left?
- Yes, complete written instructions
- Yes, but they were incomplete or hard to read
- No written instructions, verbal only
- I don't remember
Q04
MatrixRequired
Thinking about your discharge conversation, how much do you agree with each statement?
5 rows × 5 columns
- The staff explained my diagnosis or reason for the visit in terms I understood
- I understood which medications to take, stop, or change
- I understood the warning signs that would mean I should seek care again
- I knew who to call if I had questions after leaving
- I had enough time to ask questions before I left
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q05
Multiple ChoiceRequired
Was a follow-up appointment scheduled or clearly arranged before you left?
- Yes, scheduled before I left
- Yes, but I had to schedule it myself afterward
- No follow-up was needed
- I'm not sure if one was arranged
Q06
Opinion ScaleRequired
How confident did you feel about managing your recovery or condition at home right after discharge?
Scale: 0 – 10
Min:Not at all confidentMax:Completely confident
Q07
Rating Scale
How would you rate the overall clarity of your medication instructions specifically?
Range: 1 – 5
Min:Very unclearMax:Very clear
Q08
Multiple ChoiceRequired
In the 7 days after leaving, did you have to call the office, visit an ER, or get readmitted because something about the discharge instructions was unclear or wrong?
- No, everything was clear and went fine
- I called with a question but didn't need further care
- I sought additional care (ER visit, urgent care, or readmission)
- Not applicable / no issues arose yet
Q09
AI Interview
Reconstruct exactly what happened after the respondent left care: identify the single instruction (medication, activity restriction, warning sign, or follow-up step) that was least clear to them, ask what they actually did when they hit that confusion, and whether it led them to call the office, guess, ignore it, or seek additional care. If they said everything was clear, probe one specific detail (like a medication dose or a warning sign) to verify true understanding rather than general satisfaction. If they sought additional care afterward, get the specific timeline and root cause.
Q10
Long Text
Is there anything about the discharge process you'd want us to change for the next patient?
Q11
Multiple Choice
What is your age range?
- 18-29
- 30-44
- 45-59
- 60-74
- 75+
- Prefer not to say
Q12
Multiple Choice
What is your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q13
Message
Thank you for sharing your experience. Your responses go directly to our care quality team and help us improve discharge instructions and follow-up support 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.
Why this template
What this template is built to do — we found no directly comparable template from other survey tools to review.
What sets it apart
- Includes an AI follow-up interview that reconstructs exactly what happened after discharge and pinpoints the specific moment instructions became unclear, rather than only capturing a static rating
- Combines structured questions (visit type, written instructions received, follow-up appointment status, medication clarity rating, post-discharge ER/office contact) with an open-ended change request, giving both quantifiable and narrative data
- Uses a matrix question to assess agreement across multiple discharge-conversation statements plus an opinion scale for at-home recovery confidence, capturing nuance a single Likert item would miss
- Closes with a transparent message telling respondents their answers go directly to the care quality team, and separately collects age range and gender for segmentation without mixing demographics into the clinical questions
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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