UCDHS Clinical Telemedicine Consultation
Provider Satisfaction Survey
Date of Service
Appointment time
__________
__________
Reason for consultation:
How would you rate the telemedicine consultation based on the items below:
Very Dissatisfied Dissatisfied Neutral Satisfied
1. Clinical skills of the UCD physician
1
2
3
4
2. Overall telemedicine consult experience
1
2
3
4
3. Ability to present the case (patient) through
1
2
3
4
telemedicine
Very Satisfied
5
5
5
Did the telemedicine consultation result in changes or addition of patient management?
Yes ______
No ______
Did the telemedicine consultation result in additional diagnostic studies?
Yes ______
No ______
Did the telemedicine consultation facilitate peer to peer education?
Yes ______
No ______
In your opinion, how important was it that this patient receives a telemedicine consultation?
1
2
3
4
5
6
Not important
7
Very important
Please rank the degree to which the telemedicine consultation assisted in the medical management of
this patient:
1
2
3
Not at all
Please write any additional comments below:
4
5
6
7
Significantly