Paediatric Carers of Children Feedback Form for Neonatal and

Paediatric Carers of Children Feedback Form for
Neonatal and Paediatric Intensive Care (PaedCCF ICU)
Doctor’s surname
Doctor’s initials
Doctor’s GMC number
Unique form number
Please use black ink and put a cross to indicate your choice(s) for each question e.g .
provided. Use N/A (not applicable) if the question is not relevant.
Not at all /
Less than
worst I would
I would
expect
expect
1
2
Same as
expected
Not at all /
Worse/less
worst I would than I would
expect
expect
Same as
expected
3
or write within the spaces
More than I Best / most I
would
would
expect
expect
4
5
N/A
1. How much chance were you given to
discuss or do the things you wanted during the
meeting(s)?
1
2
3
More/better Completely /
than I would most I would
expect
expect
4
5
N/A
2. How well do you understand your
baby/child's condition(s) now you have seen
the doctor?
3. How well do you understand your
baby/child's treatment(s) now you have seen
the doctor?
4. How well did the doctor explain the risks of
your baby/child's condition?
5. How well did the doctor explain the risks of
the treatment of your baby/child's condition?
6. How well do you understand how you can
contribute to your baby/child's care now you
have seen the doctor?
Worst / least Worse/less
I would
than I would
expect
expect
1
2
Same as
expected
3
More/better Most/best I
than I would
would
expect
expect
4
5
N/A
7. How good with your baby/child is this
doctor?
8. How good with you is this doctor?
9. How much was the doctor interested in
your point of view when he/she was asking
questions?
10. How much was the doctor interested in
your point of view when he/she was planning
and explaining things?
11. How much was the doctor interested in
your child's point of view?
12. How well do you feel the doctor listened
to you?
© 2014 Royal College of Paediatrics and Child Health
Modified from SHEFFPAT – Crossley et al (2005) Children and their parents assessing the doctor–patient interaction: a rating system for doctors'
communication skills. Medical Education 39: 820–828
PTO
Worst / least Worse/less
I would
than I would
expect
expect
1
Same as
expected
2
More/better Most/best I
than I would
would
expect
expect
3
4
5
N/A
13. How well do you think the doctor
understood you?
14. How well did the doctor explain things?
15. How much information did this doctor
give you on where you can find further
information or support available for you
and/or your child?
16. How well did the doctor respect your
baby/child's right to privacy, dignity and
confidentiality?
17. Overall, how satisfied are you with the
doctor in this meeting(s)?
Please write in the space below if there is anything else you would like to add about this
meeting(s) e.g.was anything especially helpful; was there anything else that would have
improved the meeting(s) with your child's doctor. Please print your feedback clearly.
Your Gender
Male
Female
Your ethnic group
British
Other White background
African
Chinese
White and Caribbean
White and Asian
Other Black background
Middle Eastern
Indian
White and African
Bangladeshi
Any other ethnic group
Other Asian Background
Caribbean
Pakistani
I do not wish to answer
Who is filling out this form?
Parent/Carer
How many times have you seen the doctor?
Child/Young Person
0
1-4
Interpreter/Helper (e.g. clinic staff/nurse/other)
5-9
10+
What age is the baby/child/young person?
Completed Years:
Completed Weeks:
(enter weeks only if less than 1 year old)
If your child helped to complete this form, please check the box
It is really important for doctors to receive feedback on the care that they provide so that they can ensure that they are
giving the care that families need. We are therefore grateful to you for taking the time to fill in this short form.
The information is entirely confidential and the doctor concerned will not see the form. Your responses are combined
with many other people's responses by the Royal College of Paediatrics and Child Health and fed back to the doctor
anonymously.
Thank you again for your help.
© 2014 Royal College of Paediatrics and Child Health
Modified from SHEFFPAT – Crossley et al (2005) Children and their parents assessing the doctor–patient interaction: a rating system for doctors'
communication skills. Medical Education 39: 820–828