Patient satisfaction survey template checklist

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Health care institute or hospital is successful only when it has good review and patients are happy with the treatment and health care received. Usually, the patient satisfaction survey is done by the hospitals to know the feedback. Such surveys give a clear picture of what the system is lacking and need to improve.

General

Images

Inspectors Name/signature:

SIGNATURE

Inspection Date:

Pharmacist/Supervisor Signature:

SIGNATURE

Comments:

Do practitioners have proper prescribing credentials?

Yes No Na

Is pharmacist “on-call” service available?

Yes No Na

Is the pharmacy open for 24 hours?

Yes No Na

If the pharmacy is not open 24 hours, are there procedures for emergency access?

Yes No Na

Is the access to pharmacy limited?

Yes No Na

Does the pharmacy keep records of orders, stocks, and controlled drugs?

Yes No Na

Does the pharmacy has written policies and procedures?

Yes No Na

Does the pharmacy have adequate lighting, ventilation and moisture control?

Yes No Na

Is the refrigerator temperature checked daily?

Yes No Na

Is the pharmacy kept clean and obstruction free?

Yes No Na

Are pharmacy receipts, documents secured?

Yes No Na

Does the pharmacy entrance display working hours clearly?

Yes No Na

Is the pharmacy always under a supervision of a pharmacist?

Yes No Na

Are employment details of all registered persons working in the pharmacy updated?

Yes No Na

Are counters free of clutter?

Yes No Na

Is there any evidence of contamination?

Yes No Na

Is the pharmacy accessible to people with disabilities?

Yes No Na

Are there signs indicating that the pharmacy is a non-smoking zone?

Yes No Na

Are records maintained for daily sign in and out?

Yes No Na

Are there extinguishers in case of emergency?

Yes No Na

Are extinguishers operational?

Yes No Na

Is equipment present in the pharmacy in good condition?

Yes No Na

Are copies of prescriptions maintained?

Yes No Na

Is the pharmacist capable of solving issues relating to prescriptions?

Yes No Na

Is every prescription signed by the pharmacist?

Yes No Na

Does the pharmacy have adequate space for the safe storage of drugs and practice of pharmacy?

Yes No Na

Is the stock organized and labelled properly?

Yes No Na

Are medication cabinets locked and secured?

Yes No Na

Are any unauthorized medications kept?

Yes No Na

Is the storage area well maintained?

Yes No Na

Are hazardous and flammable materials kept appropriately?

Yes No Na

Are expired or used medicines checked, updated or disposed of if necessary?

Yes No Na

Are expired medicines separated from the operative ones?

Yes No Na

Does the pharmacy have an authorized license for selling?

Yes No Na

License/Registration number:

Yes No Na

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Patient satisfaction survey template checklist

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