Daily Patient Well-Being Rounding Log

To proactively identify patient needs, resolve issues in real time, and track satisfaction trends for inpatients

Staff & Patient Identification

Staff Member ID *

Date *

Patient IP No. *

Ward/Bed No. *

Admission Date *

SECTION B: Rounding Script & Patient Response(s)

1. How are you feeling overall today? *

Very Good Fair Not Well

Please explain why patient is not feeling well

2. Are you experiencing any pain right now? *

No pain Mild (1-3) Moderate (4-6) Severe (>10)

⚠️ Immediate escalation needed

3. Have you been able to rest/sleep comfortably? *

Yes No

Specify reason for sleep discomfort

4. Do you understand your current treatment plan? *

Yes, clearly Somewhat No

Patient needs further explanation

5. Has anyone explained the medications you're receiving? *

Yes No

Medication education needed

6. Are your personal needs being met (bathing, toileting, meals, linen mobility)? *

Yes, Fully Partially (Specify need) No → Escalate

Detail unmet needs

7. Are you registered on SHA? *

Yes No → Escalate to SHA clerk

SHA registration support needed

SECTION C: Environment & Safety Check

8. Room cleanliness:

Clean Needs attention (e.g., spills, trash)

9. Equipment functioning (bed rail, bed side locker):

Yes No → Learn breakers

10. Can patient reach personal items?

Yes No

11. Any safety concerns (fall risk, clutter, open sockets, cords on floor):

None Yes → Decrease/Escalate

Customer Care Experience Metrics

12. Courtesy and respect from all staff (1-5):

13. Responsiveness to requests and needs (1-5):

14. Environment cleanliness (1-5):

15. Quality of food and meal assistance (1-5):

16. Likelihood to recommend CGTRH to family (1-5):

Follow-up & Resolution

17. Did this rounding encounter identify any new problem?

Yes No

18. Was the problem resolved immediately?

Yes No

19. Patient's emotional state:

Calm/Positive Anxious Frustrated/Angry Sad/Wistfulness Confused

20. Follow-up action taken:

21. Supervisor notified?

Yes No

22. Rounding Outcome:

Heard/ed same staff Escalated Unresolved → Patient Experience Lead Notified

Data entered into system by:

Date: