Standards › Standard 2A › Forms
Form · CON-FRM-004 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.8
Purpose
To record a patient’s answers to fixed questions during their stay or day-care visit. The patient may decline any question.
How to complete
- Explain the purpose: to improve care. The answers are confidential and do not affect treatment.
- Ask the questions in the patient’s language, or hand over the form.
- Record the answers as given, including any comment.
- If a safety concern is raised, inform the ward head at once.
Checks
| Check | Entry |
|---|---|
| Staff explained my care and treatment clearly | Yes / Partly / No [EC] |
| I was involved in decisions about my care | Yes / Partly / No [EC] |
| I felt safe during my stay | Yes / Partly / No [EC] |
| I was treated with respect and dignity | Yes / Partly / No [EC] |
| I knew who to ask if I had a concern | Yes / Partly / No [EC] |
| Anything you would like us to change (free text) | Comment [EC] |
Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Questions to be finalised by the committee and the patient representative. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)