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Provider Rating Survey

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Provider Rating Survey

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Provider Name
Jane Martinez
Visit Date
03/15/1985
Listening and Attentiveness
Option A
Option B
Option C
Explanation Clarity
Option A
Option B
Option C
Time Spent with Patient
Option A
Option B
Option C
Empathy and Bedside Manner
Option A
Option B
Option C
Shared Decision-Making
Option A
Option B
Option C
Confidence in Provider
Option A
Option B
Option C
Would Recommend Provider
Option A
Option B
Option C
Additional Feedback
Enter details here...
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The Provider Rating Survey is designed to collect detailed patient feedback about their experience with a specific provider, enabling practices to evaluate and improve individual clinician performance. While overall satisfaction surveys capture the full visit experience, this template isolates the provider interaction so you can assess communication skills, clinical competence as perceived by the patient, empathy and bedside manner, and the degree to which the patient feels heard and respected. These provider-specific metrics are invaluable for professional development, peer benchmarking, and performance reviews.

The survey evaluates the provider across multiple dimensions that patients care about most. Patients rate how well the provider listened to their concerns, whether they explained the diagnosis and treatment plan in understandable terms, how much time they spent with the patient, and whether they involved the patient in shared decision-making. Trust-related questions assess whether the patient feels confident in the provider's medical knowledge, whether they would return to the same provider, and whether they would recommend the provider to family and friends. A question about respect and cultural sensitivity ensures that the survey captures the interpersonal dimensions of care quality.

This template serves multi-provider group practices conducting internal performance comparisons, healthcare organizations building provider scorecards, medical directors overseeing quality improvement programs, and credentialing committees gathering patient experience data. The structured format makes it easy to aggregate scores by provider, identify strengths and coaching opportunities, and track improvement over time after targeted training or mentoring interventions.

What's included

  • Listening skills and patient attentiveness assessment
  • Communication clarity and health literacy evaluation
  • Empathy, bedside manner, and respect measurement
  • Shared decision-making and patient involvement rating
  • Provider trust and confidence scoring
  • Provider recommendation likelihood and open feedback

Who uses this template

  • Multi-provider group practices benchmarking individual clinician performance
  • Medical directors building provider scorecards for quality improvement
  • Healthcare organizations supporting professional development programs
  • Credentialing committees gathering patient experience evidence

All form fields

10 fields across 1 page. Customize any field after signing up.

Provider NameText
Visit DateDate
Listening and AttentivenessMultiple Choice
Explanation ClarityMultiple Choice
Time Spent with PatientMultiple Choice
Empathy and Bedside MannerMultiple Choice
Shared Decision-MakingMultiple Choice
Confidence in ProviderMultiple Choice
Would Recommend ProviderMultiple Choice
Additional FeedbackLong Text
8 min saved per patient98% patient satisfaction3x faster than paper

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