Christiana Medical Group

CMG-Hospitalist Primary Care Physician Survey

* First Name

* Last Name

Office Phone Line

Private Phone Line

Cell Phone Number

Fax Number

* Email Address

Admissions
When my patient is admitted

	Yes	Write Answer
I want to be called no matter what time this occurs?		-----
If yes, what is the best number?	-----
I want to be called next morning?
If yes, what is the best number	-----
A printed “Notification of Admission” will suffice		-----
I also want a copy of the H+P faxed to my office
I have access to the Bayhealth Physician Portal and do not want the H+P faxed to my office

Updates

	Yes	No
I prefer them daily
I prefer to be called if there is a significant change in my patient’s status or death
I prefer to be called on discharge
A timely, comprehensive copy of the discharge summary is sufficient

Discharges
I Want

	Yes	No
Phone call from discharging physician
Phone call and discharge instruction sheet only (I have access to the Portal)
Phone call, discharge instructions and discharge summary
Discharge Summary only faxed to my office
Discharge instruction sheet faxed to my office

Post-Discharge Follow-up Appointments

	Yes	No
I prefer to have discharging physician schedule follow-up appointments
I prefer to have patients schedule their own appointments
I prefer to see my hospital discharges in 1 week/ 2 weeks/ as clinically indicated

Overall opinion of the service we have provided to date:

	Yes	Write Answer
I am satisfied with the care and level of communication		-----
I am satisfied with the care but communication can improve
I have the following concerns about care and communication
Please call me (best date and time ____)	-----

* Indicates Response Required