This printable hospital discharge survey helps wards and discharge teams capture honest feedback from every patient as they leave, in 21 questions across three pages. It reaches people who never open an email or patient portal, and it takes about five minutes to complete at the bedside or at the ward desk.
What this survey measures
The survey follows the patient from the ward to the front door. It opens with the ward, length of stay, and type of admission, then asks about care during the stay: whether staff explained the condition clearly, involved the patient in decisions, managed pain, respected dignity and privacy, and came quickly when needed, plus ratings for nursing care, doctors, cleanliness, food, and quiet at night. The leaving hospital section checks that discharge instructions, medicines, side effects, warning symptoms, self-care, and follow-up appointments were understood, and records written instructions, notice of discharge, delays, and help at home. A short getting home section confirms medicines, transport, carer involvement, and home visits. An overall rating and a likelihood-to-recommend question give you simple scores to track over time, and the comment section lets patients thank staff by name and say what went well and what could be better.
How to use it on paper
Hand the form to patients as their discharge paperwork is prepared, or leave copies at the ward desk with a drop box for completed sheets. Patients fill the checkboxes with a blue or black pen. Collect the forms and scan them in batches: PaperSurvey reads the checkbox answers with optical mark recognition and converts handwritten comments to text automatically, so results appear in your dashboard without any manual data entry.
Customize this template
Add your hospital logo, reword statements to match your ward or specialty, and add or remove questions to cover medication counseling, follow-up appointments, or transport. The paper layout reflows automatically as you edit, and every copy you print stays scannable.
Preview the PDF above, or use this template to start collecting discharge feedback today.