Scoring Reference

5 — Excellent: Proactively exceeded standard

4 — Good: Fully met standard

3 — Adequate: Partially met standard

2 — Poor: Significantly below standard

1 — Unacceptable: Standard completely absent

N/O — Not Observed during this visit

Facility Assessment Details

Complete all fields before beginning the assessment. These details will appear in your final report.

Facility Name

Facility Type

Visit Date

Visit Day

Arrival Time

Departure Time

Shopper Reference Code

Shopper Profile Used

Visit Scenario / Complaint Used

Department(s) Visited

OPEX Engagement Reference

Visit Number (in this cycle)

Pre-Visit Notes / Special Instructions from OPEX

General Observations & Shopper Reflection

Record your overall impressions, moments that stood out, and anything not captured in the scored criteria.

First Impression (arrive to first acknowledged)

Most Positive Moment of the Visit

Most Disappointing Moment

Staff Attitudes & General Culture

Physical Environment Overall

Any Patient Safety Concerns Observed

What Would Bring You Back as a Paying Patient?

Specific Staff Conduct Worth Flagging to OPEX (do NOT include names — describe role, department, approximate time)

Shopper Overall Experience Rating

Shopper Signature / Initials

Date Submitted

Time Submitted

Assessment Summary Report

Complete the assessment to generate your summary.

Score by Domain