Hsr Form

Republic of the Philippines Department of Health Manila HOSPITAL STATISTICAL REPORT For the Year: __________ Stat form 3 Name of Hospital: ___________________________Complete Address: __________________________________ Region:__________ Catchment Population:_____ Contact No___________ Fax No: _____E-mail Address:__________ (PLEASE FILL UP ALL ITEMS, N/A IF NOT APPLICABLE) 1.

Classification:

1.1

Service Capability: 1.2 [ ] Level 1/Infirmary [ ] Level 2/Primary Care [ ] Level 3/Secondary Care (Non-Teaching and Non-Training) [ ] Level 4/ Tertiary Care (Teaching and Training)

1.3

Nature of Ownership: Government: [ ] National – DOH Retained/Renationalized [ ] Local [ ] Other Government Agency, specify ____________

2.

3

[ ] General [ ] Special, Specify ___________

Private: [ / ] Single Proprietorship/Partnership/Corp. [ ] Religious [ ] Foundation

Quality Management: [ ] Certified ISO, Specify _________ Validity Period _________________ [ ] PCAHO Validity Period _________________ [ ] Other Certifying Body, Specify ________________ Validity Period _________________ Bed Capacity/Occupancy: 3.1 Authorized Bed Capacity _______ beds 3.2 Actual/ Implementing Beds ____ beds 3.3 Bed Occupancy Rate ( BOR) Based on Authorized Beds _____________ % Total In-patient service days for the period* (Total no. of authorized beds) x (Total days in the period) x 100 3.4 Bed count: Number of beds per Service based on actual Bed Capacity No. of Beds No. of Beds per Classification: Pay _________________ Service _________________ No. of Beds per Service: Medicine _________________ Obstetrics _________________ Gynecology _________________ Pediatrics _________________ Surgery _________________ Pedia _________________ Adult _________________ Others: Specify _______ _________________ TOTAL _________________

* In- Patient Service Days (Bed Days) = [(In patients remaining at midnight…+ Total Admission) (Total Discharges/deaths) + (Admitted and Discharge on the same day)] 4 Staffing Pattern Actual No. of Personnel PERSONEL Permanent Contractual TOTAL Medical Specialist/Consultant Surgeon Physician Chief Nurse Supervising Nurse Staff Nurse Staff Nurse-CCU Nursing Attendant Midwife Dentist Physical Therapist Pharmacist MedTech Radiologist Medical records Officer Medical Social Worker Engineer Others, Specify

5. Committees EXISTING YES NO 5.1 Technical Medical Audit Infection Control Committee Pharmaceutical/Therapeutic Committee Tissue Committee Waste Management committee Blood Transfusion Safety Committee 5.2 Administrative Bidding and Awards Committee Records Management Improvement Committee Finance Committee 5.3 Quality Assurance Medical records Committee 5.4 Others, Please Specify

REMARKS

6. Other Facility/Service available FACILITY

EXISTING Yes No

a. Blood Bank b. Blood Collection Unit/Blood station c.Dialysis Clinic d. Drug Testing Laboratory e. HIV Testing Laboratory f. MedTech Intern Training Laboratory g.Rehabilitation Center h.Water testing laboratory i.Newborn Screening Center j.Kidney Transplant Facility k.Ambulatory Surgical Clinic l.Others Please Specify

7. 7.1 7.2 7.3

Financial Status Total Budget Total Income Total Expenditure

__________ __________ __________

REMARKS

2.3Ten (10) Leading Causes of Discharges (Morbidity) Discharge Diagnosis (Primary) No Abbreviation

Age Distribution of Patients Under 1 M F

1-4 M

5-9 F

M

F

10-14

15-19

20-44

45-64

=>65

M

M

M

M

M

F

F

F

F

TOTAL F

M

F

T

ICD-10 CODE/ TABULATION LIST

1 2 3 4 5 6 7 8 9

10 2.4 Total No. of Deliveries 2.4.1 Normal ___________ 2.4.2 Caesarian _________ 2.4.3 Others ____________ 3. DEATHS 3.1 Types of Death: 3.1.1 No. Fetal Death-Less than 22 completed weeks or <500g.birth weight ________________ 3.1.2 No. Fetal Death- 22 or more completed weeks or 500g.or more birth weight ___________ 3.1.3 No. Neonatal Death ____________ 3.1.4 No. Infant Death _______________ 3.1.5 No. Material Death _____________ 3.1.6 No. E R Death ________________ 3.1.7 No. Dead on Arrival ___________ 3.2 Gross Death Rate _______________% Gross Death Rate = Total Deaths (including newborn for a given period) Total Discharges and Deaths for the same period x 100 3.3 Net Death rate _________________ % Net Death Rate = Total Deaths (including newborn fro a given period) – Deaths < 48 hours for the period Total Discharges (including deaths and newborn) – deaths < 48 hours for the period x 100 3.4 Ten ( 10 ) Leading Causes of Deaths ( Mortality )

Discharge Diagnosis (Underlying) No Abbreviation 1. 2. 3. 4. 5. 6. 7. 8. 9.

10.

Age Distribution of Patients Under 1 M F

1-4 M

5-9 F

M

F

10-14

15-19

20-44

45-64

=>65

M

M

M

M

M

F

F

F

F

TOTAL F

M

F

T

ICD-10 CODE/ TABULATION LIST

4

HOSPITAL INFECTION RATE ( NOSCOMICAL INFECTION) 4.1 Gross Infection Rate ____________ % Total no. of infection in the hospital (ward) for the period x 100 Total discharges and deaths from the hospital (ward) for the same period 4.2 Net Infection Rate ____________ % Total no. of infection debited against the hospital (ward) for the period x 100 Total discharges and deaths from the hospital (ward) for the same period

5

SURGICAL OPERATIONS Types of operations

Major Operation (excl.CS) Caesarian Operation Minor Operation (In-Pt) Minor Operation (Out-Pt)

6

=<19 y.o. MALE FEMALE

=> 20 y.o. MALE FEMALE

xxxxxx

xxxxxx

MALE

TOTAL

xxxxxx

E R SERVICES ( N/A if not applicable) 6.1 Total No. of Patients Attended: _______________ 6.2 Average No. of E R patients per day ___________ 6.3 Ten (10) Leading Causes of Emergency cases in the E R Department Causes

No. of Consultation

1. 2. 3. 4. 5.

Causes

No. of Consultation

6. 7. 8. 9 10.

7. OUT –PATIENTS SERVICES 7.1 Total No. of Patients attended: New: 167 Re-visit: 27 7.2 Average Number of Out –patient per day: 2.12% 7.3 Ten (10) Leading Causes of Consultations at OPD Causes 1. 2. 3. 4. 5.

ALL AGES FEMALE

No. of Consultation

Causes

Total: 194

No. of Consultation

6. 7. 8. 9. 10.

III. OTHER HOSPITAL SERVICES I. DIETARY SERVICE 1.1 No. of Meals Served: Routine Diets _____________ Therapeutics Diets _____________ TOTAL___________ 1.2 No. of Patients Given Diet Counseling: __________

2. RADIOLOGICAL/LABORATORY SERVICES No. In patients

No. Out Patients

TOTAL

2.1 RADIOLOGICAL PROCEDURE 2.1.1 X-RAY 2.1.2 ULTRSOUND 2.1.3 CT-SCAN 2.1.4 M R I 2.1.5 MAMMOGRAPHY 2.1.6 ANGIOGRAPHY 2.1.7 LINEAR ACCELERATOR 2.1.8 DENTAL X-RAY 2.1.9 OTHER, Specify 2.2 LABORATORY SERVICE 2.2.1 CLINICAL LABORATORY URINALYSIS FECALYSIS HEMATOLOGY CLINICAL CHEMISTRY IMMUNOLOGY/SEROLOGY/HIV MICROBIOLOGY( Smears/culture & Sensitivity) 2.2.2 ANATOMIC PATHOLOGY SURGICAL PATHOLOGY AUTOPSY CYTOLOGY 2.2.3 BLOOD BANK BLOOD COLLECTED Voluntary Donor Replacement Donor BLOOD TRANSFUSED 3. OTHER ACTIVITIES PERFORMED: (N/A if not applicable) 3.1 Ambulance calls/conduction _______ 3.2 No. Autopsies performed _________ 3.3 No. Medico-legal Cases _____ (exclude ER and DOA pt.)

Prepared by

: ________________

Designation/Section/Dept.: _______________

Date: ___________

APPROVED & CERTIFIED BY: ROSENDO C. REDOBLE, M.D Chief of Hospital/Medical Director

Date: ___________

C:f/forms.statform3_hosp_406.doc