Form Cms-806a - Quality Of Life Assessment - Resident Interview (Page 4 of 4) in pdf

Form Cms-806a - Quality Of Life Assessment - Resident Interview Page 4

RESIDENT INTERVIEW

9. MEDICAL SERVICES: (F156, 163, 164, 250, 411,

Do you see your physician here or at the office?

412)

(If they say here) Where in the facility does your doctor

Who is your physician?

see you?

Did you choose your physician yourself?

Do you have privacy when you are examined by your

(If no, probe for details about who selected the physi-

physician?

cian and why the resident did not do it.)

(If they say they go to the office) How do you get to the

Are you satisfied with the care provided by your

office?

physician?

Do facility staff help you make doctor's appointments

Can you see your doctor if you need to?

and help you obtain transportation?

Can you get to see a dentist, podiatrist, or other

specialist if you need to?

10. (Write here any special items not already discussed that you have noted about this resident or about the facility

that you would like to discuss with the resident.)

11. Is there anything else you would like to talk about regarding your life here?

Thank the resident. Review your notes from this interview and determine if there are any concerns you

need to investigate further. Share any problems you have found with the team so they may keep them in

mind during the remainder of the survey.

Form CMS-806A (07/95)

Form Cms-806a - Quality Of Life Assessment - Resident Interview Page 4