Hi, This Is ______, I M Calling from Cape Canaveral Hospital

Cape Canaveral Hospital Heart Failure Patient Follow-up Phone Survey

Hi, this is ______; I’m calling from Cape Canaveral Hospital. I am calling to see how you are doing now that you are home. If you have time I would like to ask you a few questions. This information will be used to improve the care provided to our patients.

1. Have you scheduled your follow-up appointment with your doctor? Yes No If No, are you planning to do so? Yes No If No, again, why not? ______Who is the appointment with  Primary Care Physician  Cardiologist  Other ______

2. How often do you weigh yourself? ______

3. When would you call your doctor? ______

4. Do you have any diet restrictions? Yes No (opportunity to discuss salt and fluid restrictions)

5. Did you receive a list of your medications on discharge? Yes No

6. Did you get your prescriptions filled? Yes No If No, Why not ______

7. Are you taking your medications as ordered? Yes No If No, Why not? ______

8. Did you find the education material provided to you to be helpful? Yes No If No, why not? ______

9. Did you smoke at the time of your admission? Yes No If Yes, have you quit? Yes No

10. Do you have Home Health Care? Yes No (if applicable) Did the Home Health nurse call or visit within 24 hours? Yes No Did you find the Home Health nurses helpful to you? Yes No If Yes, in what way?______If No, why not; how could they be more helpful?______

11. How would you rate your overall care while at CCH, 1-5, 5 being extremely satisfied and 1 being extremely dissatisfied? 1 2 3 4 5

Thank you for taking the time to answer the questions. Remember to call your physician if you experience the following signs and symptoms of ‘heart failure” – fatigue, chest congestion, edema or ankle swelling, shortness of breath and weight gain of more than 2 pounds. Remember Heart Failure is a medical emergency; please be sure to seek help if you have symptoms of heart failure. You may receive a patient satisfaction survey in the mail, if you should receive a survey, please remember to complete and return your patient satisfaction survey when it comes in the mail.

CCH “heart failure” follow-up phone call survey 12/2008 Revised: 2/2009