Emergency Room Feedback Template: Improving Patient Care

An emergency room feedback template asks patients and the relatives who came with them about one ER visit: how quickly they were seen, how staff treated them and how well things were explained. ER feedback needs its own short form because patients arrive unplanned, often in pain, and many go home within hours. The general reasons for collecting patient feedback are covered in our hospital feedback form template; this article gives three ready ER forms and the questions that matter most in emergency care.

Top Emergency Room Feedback Template Examples

Example 1: Quick ER Rating Form (Five Face-Scale Questions)

A one-page form headed "General Patient Experience Survey" that the patient or a relative fills in before leaving the ER, on paper or a tablet. Every question uses the same five-point face scale, so it takes under a minute and is easy to average. It starts with name and date.

1. How would you rate the efficiency of the check-in process? (Bad / Poor / Average / Good / Excellent)
2. How would you rate the attentiveness of the doctors and nurses? (Bad / Poor / Average / Good / Excellent)
3. How comfortable was the waiting area during your visit? (Bad / Poor / Average / Good / Excellent)
4. How would you rate the communication skills of the medical staff? (Bad / Poor / Average / Good / Excellent)
5. How would you rate your overall experience in the ER? (Bad / Poor / Average / Good / Excellent)

Example 2: Detailed Emergency Room Feedback Form With Comments

Titled "Emergency Room Feedback", this version suits a follow-up after the visit, by SMS link or phone. Each question has answer options worded for that question, and it ends with a comment box, so it tells you more about why a patient was unhappy. It starts with name and date.

1. How would you rate the overall quality of care you received in the Emergency Room? (Excellent / Good / Fair / Poor)
2. How satisfied were you with the wait time before being seen by a healthcare professional? (Very satisfied / Satisfied / Neutral / Dissatisfied / Very dissatisfied)
3. Were the staff members (nurses, doctors and other personnel) courteous and professional? (Always / Most of the time / Sometimes / Rarely / Never)
4. How well did the medical staff explain your diagnosis and treatment options? (Very clearly / Somewhat clearly / Not very clearly / Not at all clearly)
5. Do you have any suggestions or comments on how we can improve the quality of our emergency room service? (comment)

Example 3: Mixed-Format ER Form With Actual Waiting Time

Also headed "General Patient Experience Survey", this form overlaps with Example 1 (check-in, attentiveness, communication) but replaces the comfort and overall ratings with two factual questions: how long the patient actually waited and a yes/no on the care. Use it when waiting time is the problem you are trying to measure. It starts with name and date.

1. How long did you wait before being seen by a medical professional? (Less than 15 minutes / 15 to 30 minutes / 30 to 60 minutes / Over 60 minutes)
2. Were you satisfied with the care provided by the medical staff? (Yes / No)
3. Rate the efficiency of the check-in process. (Bad / Poor / Average / Good / Excellent)
4. Rate the attentiveness of doctors and nurses. (Bad / Poor / Average / Good / Excellent)
5. Rate the communication skills of the medical staff. (Bad / Poor / Average / Good / Excellent)

Key Elements Of An Effective Emergency Room Feedback Template

Most ER complaints come down to waiting, not knowing what is happening, and how staff spoke to a frightened patient or family. Write questions that separate these, so a low score points to a specific fix:

• Visit details: date, time of arrival and whether the patient went home or was admitted. Name and phone number should be optional, with a tick box for "please contact me".
• Waiting, in two parts: how long until a nurse first assessed them, and how long until a doctor saw them. Add "Were you told roughly how long you would wait? (Yes / No)", so you can tell whether the problem is the wait itself or not being told about it.
• Explanations: whether the diagnosis, tests and treatment were explained, and whether the patient knew what to do after leaving (medicines, warning signs, follow-up).
• Staff behaviour: courtesy and attentiveness of doctors, nurses and the registration or billing desk, asked separately.
• Pain and comfort: whether pain was managed while waiting, and the comfort and cleanliness of the waiting area and bays.
• Family: whether relatives were kept informed. In an ER the person giving feedback is often the relative, not the patient.
• Overall rating and one comment box: "What one thing should we change?" gets more usable answers than "Any comments?".

When To Collect ER Feedback and Who Should Act on It

• Timing: never ask during treatment. Offer a QR code or tablet at the exit for patients going home, or send a link the same day. For patients admitted from the ER, add two or three ER questions to the inpatient survey rather than sending a separate form.
• Who answers: let a relative or attendant complete the form on the patient's behalf, and record that they did.
• Who sees it: the ER nurse in charge should see low scores and comments daily; the ER head and quality team should review the monthly trend by shift and day of the week, to see whether problems cluster at particular times.
• How fast to act: treat any comment about safety, a missed diagnosis or staff behaviour as a complaint, and contact the patient or family promptly. See our guide to handling patient complaints in hospitals.
• Closing the loop: put the main changes made from feedback on a notice in the waiting area, so patients see that forms are read.

Common Mistakes With ER Feedback Forms

• Using the full inpatient survey in the ER. Five to eight questions is enough.
• Asking only "How was the wait?" without asking how long it was, which makes it impossible to set a target.
• Making name and phone number mandatory, which puts off honest criticism.
• Reporting one average score for the whole ER, which hides the shift or area where problems happen.

Frequently Asked Questions