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Multidisciplinary Clinic

Quality Nurse Navigator Questionnaire

Two-Part Survey

This questionnaire has two sections: one for the Quality Nurse Navigator to complete prior to the patient visit, and one for the Patient or Caregiver to complete at the end of the appointment.

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Part 1: Nurse Navigator

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Part 2: Patient/Caregiver

Part 1: Quality Nurse Navigator Complete prior to patient visit

Question 1

Is this patient new to the Brain and Spine Metastasis/Primary Brain Tumor Multidisciplinary Clinic?

Yes

No

Part 1: Quality Nurse Navigator Complete prior to patient visit

Question 2

Did Quality Nurse Navigator speak with the patient or representative on a call prior to visit?

Yes

No

Part 1: Quality Nurse Navigator Complete prior to patient visit

Question 3

Is the patient able to make decisions in their healthcare?

Yes

No

Part 2: Patient/Caregiver Complete at end of appointment

Question 1

Who is completing this survey?

Patient

Caregiver

Other

Part 2: Patient/Caregiver Complete at end of appointment

Question 2

Is this the patient's first time in this Multidisciplinary Clinic?

Yes

No

Part 2: Patient/Caregiver Complete at end of appointment

Question 3

Did you receive a pre-visit phone call from our nurse?

Yes

No

Part 2: Patient/Caregiver Complete at end of appointment

Question 3a

Were you able to clearly understand the expectations for this visit?

Yes

No

Part 2: Patient/Caregiver Complete at end of appointment

Question 4

During your visit, did the care team explain the next steps in your care in a way that you could understand?

Yes

Somewhat

No at all

Part 2: Patient/Caregiver Complete at end of appointment

Question 5

How would you rate your visit overall?

😊 Excellent

🙂 Good

😐 Poor

Review

Review Your Responses

Please review your answers before submitting

Part 1: Quality Nurse Navigator

New to Brain and Spine Metastasis/Primary Brain Tumor Multidisciplinary Clinic -

Quality Nurse Navigator spoke with patient prior to visit -

Patient able to make healthcare decisions -

Part 2: Patient/Caregiver

Who completed this survey -

First time in Multidisciplinary Clinic -

Received pre-visit phone call -

Understood expectations for visit -

Care team explained next steps clearly -

Overall visit rating -

Thank you!

Your responses will help us be of greater value to you