NCHFD Hosp Stat Form 1

Republic of the Philippines

Department of Health
NATIONAL CENTER FOR HEALTH FACILITY DEVELOPMENT
Manila

HOSPITAL STATISTICAL REPORT

For the quarter/year __________________

(Name of Hospital) (Address of Hospital)

Region: Classification :
Category :

1 IN-PATIENT'S DEMOGRAPHIC DATA

1.1 Congressional districts within the province

Number of Patients
Pay Service
% of
Districts Non PHIC HMO Non PHIC Grand
PHIC Member/Dep Indigent w/ PHIC w/o PHIC OWWA PHIC Member/Dep Indigent OWWA Total Total
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
Grand Total 0 0 0 0 0 0 0 0 0 0 0

1
 2

1.2 Congressional districts outside the province but within the region

Number of Patients
Pay Service
% of
Districts Non PHIC HMO Non PHIC Grand
PHIC Member/Dep Indigent w/ PHIC w/o PHIC OWWA PHIC Member/Dep Indigent OWWA Total Total
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
Grand Total 0 0 0 0 0 0 0 0 0 0 0

1.3 Congressional districts outside the region

Number of Patients
Pay Service
% of
Districts Non PHIC HMO Non PHIC Grand
PHIC Member/Dep Indigent w/ PHIC w/o PHIC OWWA PHIC Member/Dep Indigent OWWA Total Total
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
Grand Total 0 0 ###
0 0 0 0 0 0 0 0 0
 3

2. BED CAPACITY AND OCCUPANCY

2.1 Authorized Bed Capacity beds
2.2 Implementing Beds beds
2.3 Actual Beds beds
2.4 Additional Beds Used 0 beds
* Additional Beds Used = Actual Beds - Implementing Beds

2.4 Distribution of Beds

Actual Number of Beds Utilized
Total In-
Allocated No. of Beds Patient Actual No. of Staff Full Time
Type of Service Philhealth/
Non-Philhealth Total Service BOR (%) Equivalent
OWWA/HMO
Days
Pay Srvc Total Pay Srvc Pay Srvc Pay Srvc Total FT PT

Medicine 0 0 0 0
Obstetrics 0 0 0 0
Gynecology 0 0 0 0
Pediatrics 0 0 0 0

Surgery 0 0 0

Adult 0 0 0 0

Pedia 0 0 0 0

Others 0 0 0 0

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Newborn(born alive)
Pathologic

Non Pathologic xxx xxx xxx xxx xxx xxx xxx xxx xxx
* Bed Days (In-Patient Service Days) = [(In-patients remaining at midnight+Total Admissions)-Total Discharges/Deaths]
+ [Admitted and discharged on the same day]
* Srvc= Service FT= Full time PT= Part time
2.6 Average Daily Census of Admitted Patients
* Ave. daily census of admitted patients = Total in -patient service days for the period
Total days in the period
2.7 Percentage of Occupancy/Bed Occupancy Rate (BOR)

2.7.1 Based on Authorized Bed =

* Bed Occupancy Rate (BOR) = Total in -patient service days for the period * 100
(Total no. of authorized bed) * (Total days in the period)
2.7.2 Based on Implementing Bed =
* Bed Occupancy Rate (BOR) = Total in -patient service days for the period * 100
(Total no. of implementing beds) * (Total days in the period)
3 HOSPITAL OPERATIONS
3.1 Summary of patients in the hospital
3.1.1 Patients remaining in the hospital as of midnight last day of previous day/month/quarter/year
3.1.2 Total Admissions, Excluding Newborn
3.1.3 Total Discharges (alive)
3.1.4 Total Inpatient Deaths
3.1.5 Total Patients remaining at midnight last day of the quarter/year 0
3.1.6 Referrals 0
3.1.6.1 From RHU
3.1.6.2 From Lower Health Facilities
3.1.6.3 From Higher Health Facilities
3.1.6.4 To RHU
3.1.6.5 To Lower Health Facilities
3.1.6.6 To Higher Health Facilities
 4

3. HOSPITAL OPERATIONS (Cont.)

3.2 Discharges

3.2.1 Services rendered and patients attended

Type of Accomodations
Pay Service
Type of Service PHIC HMO PHIC
Non- Total
OWWA Non-PHIC OWWA
PHIC Member / Member / Length
Dep Indigent W/ PHIC W/O PHIC Dep Indigent Total of Stay
Medicine 0
Obstetrics 0
Gynecology 0
Pediatrics 0
Surgery 0
Adult 0
Pedia 0
Others (specify) 0
Total 0 0 0 0 0 0 0 0 0 0 0 0
Newborn (born alive)
Pathologic 0
Non-Pathologic 0

Grand Total 0 0 0 0 0 0 0 0 0 0 0 0

3.2.2 Average Length of Stay (ALOS) of admitted patients : days

* Average Length of Stay = Total length of stay of discharged patients (incl.deaths) in the period
Total discharges and deaths in the period

3.2.3 Average Length of Stay (ALOS) of newborns: days

* Average Length of Stay = Total length of stay of newborns (incl.deaths) in the period
Total discharges and deaths newborns in the period

3.3 Result of Treatment/Condition on Discharge

Result of Treatment/Condition on Discharge
Type of Service Recovered Improved Unimproved Died Total
Disch Trans Hama Abs Total Disch Trans Hama Abs Total Disch Trans Hama Abs Total <48 >=48 Total

Medicine 0 0 0 0 0

Obstetrics 0 0 0 0 0

Gynecology 0 0 0 0 0

Pediatrics 0 0 0 0 0

Surgery 0 0 0 0 0

Adult 0 0 0 0 0

Pedia 0 0 0 0 0

Others (specify) 0 0 0 0 0
Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Newborn (born alive)
Pathologic 0 0 0 0 0
Non-Pathologic 0 0 0 0 0
Grand Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 5

Disch = Discharged Trans = Trasferred Hama = Home Against Medical Advise Abs = Absconded
 5

3 HOSPITAL OPERATIONS

3.4 Twenty Leading Causes of Morbidity (Over-all)

Age Distribution of Patients

Total ICD 10
Discharge Diagnosis (Primary) <1 1-4 5-9 10-14 15-19 20-44 45-64 =>65 % of Total Total Cost Tab #
M F M F M F M F M F M F M F M F M F T
1. 0 0 0 #DIV/0!

2. 0 0 0 #DIV/0!

3. 0 0 0 #DIV/0!

4. 0 0 0 #DIV/0!

5. 0 0 0 #DIV/0!

6. 0 0 0 #DIV/0!

7. 0 0 0 #DIV/0!

8 0 0 0 #DIV/0!

9. 0 0 0 #DIV/0!

10. 0 0 0 #DIV/0!

11 0 0 0 #DIV/0!

12 0 0 0 #DIV/0!

13 0 0 0 #DIV/0!

14 0 0 0 #DIV/0!

15 0 0 0 #DIV/0!

16 0 0 0 #DIV/0!

17 0 0 0 #DIV/0!

18 0 0 0 #DIV/0!

19 0 0 0 #DIV/0!

20. 0 0 0 #DIV/0!

21 Others 0 0 0 #DIV/0!

Total xxx
 6

3 HOSPITAL OPERATIONS (Cont.)

3.5 Twenty Leading Causes of Discharges of Major Services

3.5.1 Medicine

Condition on Discharge
Discharged Diagnosis (Primary) Imroved Unimproved Total ICD-10 Code
M F Total M F Total M F
1. 0 0 0 0
2. 0 0 0 0
3. 0 0 0 0
4. 0 0 0 0
5. 0 0 0 0
6. 0 0 0 0
7. 0 0 0 0
8. 0 0 0 0
9. 0 0 0 0
10. 0 0 0 0
11. 0 0 0 0
12. 0 0 0 0
13. 0 0 0 0
14. 0 0 0 0
15. 0 0 0 0
16. 0 0 0 0
17. 0 0 0 0
18. 0 0 0 0
19. 0 0 0 0
20 0 0 0 0
21. Others 0 0 0 0
Total 0 0 0 0 0 0 0 0

3.5.2 Surgery
Condition on Discharge
Discharged Diagnosis (Primary) Recovered Improved Unimproved Total ICD-10 Code
M F Total M F Total M F Total M F
1. 0 0 0 0 0
2. 0 0 0 0 0
3. 0 0 0 0 0
4. 0 0 0 0 0
5. 0 0 0 0 0
6. 0 0 0 0 0
7. 0 0 0 0 0
8. 0 0 0 0 0
9. 0 0 0 0 0
10. 0 0 0 0 0
11. 0 0 0 0 0
12. 0 0 0 0 0
13. 0 0 0 0 0
14. 0 0 0 0 0
15. 0 0 0 0 0
16. 0 0 0 0 0
17. 0 0 0 0 0
18. 0 0 0 0 0
19. 0 0 0 0 0
20 0 0 0 0 0
21. Others 0 0 0 0 0

Total 0 0 0 0 0 0 0 0 0 0 0
7
 8

3.5.3 Obstetrics
Condition on Discharge
Discharged Diagnosis (Primary) ICD-10 Code
Recovered Improved Unimproved Total
1. 0
2. 0
3. 0
4. 0
5. 0
6. 0
7. 0
8. 0
9. 0
10. 0
11. 0
12. 0
13. 0
14. 0
15. 0
16. 0
17. 0
18. 0
19. 0
20 0
21. Others 0

Total 0 0 0 0

3.5.4 Gynecology
Condition on Discharge
Discharged Diagnosis (Primary) Recovered Improved Unimproved Total ICD-10 Code
M F Total M F Total M F Total M F
1. 0 0 0 0 0
2. 0 0 0 0 0
3. 0 0 0 0 0
4. 0 0 0 0 0
5. 0 0 0 0 0
6. 0 0 0 0 0
7. 0 0 0 0 0
8. 0 0 0 0 0
9. 0 0 0 0 0
10. 0 0 0 0 0
11. 0 0 0 0 0
12. 0 0 0 0 0
13. 0 0 0 0 0
14. 0 0 0 0 0
15. 0 0 0 0 0
16. 0 0 0 0 0
17. 0 0 0 0 0
18. 0 0 0 0 0
19. 0 0 0 0 0
20 0 0 0 0 0
21. Others 0 0 0 0 0

Total 0 0 0 0 0 0 0 0 0 0 0
 9

3.5.5 Pediatric

Condition on Discharge

Unimproved Total
Discharged Diagnosis (Primary) ICD-10 Code
Imroved

M F Total M F Total M F

1. 0 0 0 0

2. 0 0 0 0

3. 0 0 0 0

4. 0 0 0 0

5. 0 0 0 0

6. 0 0 0 0

7. 0 0 0 0

8. 0 0 0 0

9. 0 0 0 0

10. 0 0 0 0

11. 0 0 0 0

12. 0 0 0 0

13. 0 0 0 0

14. 0 0 0 0

15. 0 0 0 0

16. 0 0 0 0

17. 0 0 0 0

18. 0 0 0 0

19. 0 0 0 0

20 0 0 0 0

21. Others 0 0 0 0

Total 0 0 0 0 0 0 0 0
 9

3.6 Number of Deliveries

Age Distribution of Patients

Type of Deliveries Total
10-14 15-19 20-44 45-64
1. Normal 0
2. Caesarian 0
3. VBAC 0
4. Breech Extraction 0
5. Forceps 0
6. Vacuum/Ventose 0
Total 0 0 0 0 0

3.7 Abortion

Category of Abortion
Type
Spontaneous Induced Total
1. Non-Septic
a. Complete 0
b. Imminent 0
c. Inevitable 0
d. Incomplete 0
2. Septic
a. Complete 0
b. Imminent 0
c. Inevitable 0
d. Incomplete 0
Sub-Total
3. Threatened 0
4. Blighted Ovum 0
5. Missed Abortion 0
Total 0 0 0
3.8 Deaths
3.8.1 Types of Deaths
Types of Deaths Number Rate
1 Fetal Death
a. <22 completed weeks or <500 g. birth weight
b. 22 or more completed weeks or 500 g. or more birth weight
Born in the Born outside the
2 Neonatal Death Hospital hospital
Total

a. Neonatal Period I (from birth to <24 hrs) 0

b. Neonatal Period II (24th hr of life to < 7 days) 0
c. Neonatal Period III (7th day of life to <28 days) 0
d. Infant Death 0

3 Maternal Death
a. Early Maternal Death
(while pregnant or within 42 days of termination of pregnancy)
1) Direct Obstetric Death
2) Indirect Obstetric Death
b. Late Maternal Death
(more than 42 days but less than 1 year after termination of pregnancy)
1) Direct Obstetric Death
2) Indirect Obstetric Death
4 Post O.P. Death
5 Gross Death Rate
6 Net Death Rate
7 ER Death
8 Dead on Arrival (DOA)
* Gross Death Rate = Total Deaths (including newborn for a given period ) X 100
Total Discharges and Deaths for the same period
 10

* Net Death Rate = Total Deaths (including newborn for a given period ) - Deaths <48 hours for the period X 100
Total Discharges (including deaths and newborn) - death<48 hours for the period
 10

3.8.2 Twenty Leading Causes of Mortality

Age Distribution of Patients

Total
<1 1-4 5-9 10-14 15-19 20-44 45-64 =>65 ICD 10
Cause of Death (Underlying) % of Total Total Cost Tab #
M F M F M F M F M F M F M F M F M F T
1. 0 0 0 #DIV/0!

2. 0 0 0 #DIV/0!

3. 0 0 0 #DIV/0!

4. 0 0 0 #DIV/0!

5. 0 0 0 #DIV/0!

6. 0 0 0 #DIV/0!

7. 0 0 0 #DIV/0!

8 0 0 0 #DIV/0!

9. 0 0 0 #DIV/0!

10. 0 0 0 #DIV/0!

11 0 0 0 #DIV/0!

12 0 0 0 #DIV/0!

13 0 0 0 #DIV/0!

14 0 0 0 #DIV/0!

15 0 0 0 #DIV/0!

16 0 0 0 #DIV/0!

17 0 0 0 #DIV/0!

18 0 0 0 #DIV/0!

19 0 0 0 #DIV/0!

20. 0 0 0 #DIV/0!

21 Others 0 0 0 #DIV/0!

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 xxx
 11

3.8.3 Twenty Leading Causes of Mortality of 4 Major Services

3.8.3.1 Medical
Age Distribution of Patients
Total ICD 10
Cause of Death (Underlying) <1 1-4 5-9 10-14 15-19 20-44 45-64 =>65 % of Total Total Cost Code
M F M F M F M F M F M F M F M F M F T
1. 0 0 0 #DIV/0!

2. 0 0 0 #DIV/0!

3. 0 0 0 #DIV/0!

4. 0 0 0 #DIV/0!

5. 0 0 0 #DIV/0!

6. 0 0 0 #DIV/0!

7. 0 0 0 #DIV/0!

8 0 0 0 #DIV/0!

9. 0 0 0 #DIV/0!

10. 0 0 0 #DIV/0!

11 0 0 0 #DIV/0!

12 0 0 0 #DIV/0!

13 0 0 0 #DIV/0!

14 0 0 0 #DIV/0!

15 0 0 0 #DIV/0!

16 0 0 0 #DIV/0!

17 0 0 0 #DIV/0!

18 0 0 0 #DIV/0!

19 0 0 0 #DIV/0!

20. Others 0 0 0 #DIV/0!

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 xxx
 12

3.8.3.2 Surgical
Age Distribution of Patients
Total ICD 10
Cause of Death (Underlying) <1 1-4 5-9 10-14 15-19 20-44 45-64 =>65 % of Total Total Cost Code
M F M F M F M F M F M F M F M F M F T
1. 0 0 0 #DIV/0!

2. 0 0 0 #DIV/0!

3. 0 0 0 #DIV/0!

4. 0 0 0 #DIV/0!

5. 0 0 0 #DIV/0!

6. 0 0 0 #DIV/0!

7. 0 0 0 #DIV/0!

8 0 0 0 #DIV/0!

9. 0 0 0 #DIV/0!

10. 0 0 0 #DIV/0!

11 0 0 0 #DIV/0!

12 0 0 0 #DIV/0!

13 0 0 0 #DIV/0!

14 0 0 0 #DIV/0!

15 0 0 0 #DIV/0!

16 0 0 0 #DIV/0!

17 0 0 0 #DIV/0!

18 0 0 0 #DIV/0!

19 0 0 0 #DIV/0!

20. Others 0 0 0 #DIV/0!

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 xxx
 13

3.8.3.3 Obstetrics
Age Distribution of Patients
ICD 10
Cause of Death (Underlying) 10-14 15-19 20-44 45-64 =>65 Total % of Total Total Cost Code

1. 0 #DIV/0!

2. 0 #DIV/0!

3. 0 #DIV/0!

4. 0 #DIV/0!

5. 0 #DIV/0!

6. 0 #DIV/0!

7. 0 #DIV/0!

8 0 #DIV/0!

9. 0 #DIV/0!

10. 0 #DIV/0!

11 0 #DIV/0!

12 0 #DIV/0!

13 0 #DIV/0!

14 0 #DIV/0!

15 0 #DIV/0!

16 0 #DIV/0!

17 0 #DIV/0!

18 0 #DIV/0!

19 0 #DIV/0!

20. Others 0 #DIV/0!

Total 0 0 0 0 0 0 xxx
 14

3.8.3.4 Gynecology
Age Distribution of Patients
ICD 10
# Cause of Death (Underlying) 10-14 15-19 20-44 45-64 =>65 Total % of Total Total Cost Code

1. 0 #DIV/0!

2. 0 #DIV/0!

3. 0 #DIV/0!

4. 0 #DIV/0!

5. 0 #DIV/0!

6. 0 #DIV/0!

7. 0 #DIV/0!

8 0 #DIV/0!

9. 0 #DIV/0!

10. 0 #DIV/0!

11 0 #DIV/0!

12 0 #DIV/0!

13 0 #DIV/0!

14 0 #DIV/0!

15 0 #DIV/0!

16 0 #DIV/0!

17 0 #DIV/0!

18 0 #DIV/0!

19 0 #DIV/0!

20. Others 0 #DIV/0!

Total 0 0 0 0 0 0 xxx
 15

3.8.3.5 Pediatric
Age Distribution of Patients
Total
<1 1-4 5-10 10-14 ICD 10
# Cause of Death (Underlying) % of Total Total Cost Code

M F M F M F M F M F T
1. 0 0 0 #DIV/0!

2. 0 0 0 #DIV/0!

3. 0 0 0 #DIV/0!

4. 0 0 0 #DIV/0!

5. 0 0 0 #DIV/0!

6. 0 0 0 #DIV/0!

7. 0 0 0 #DIV/0!

8 0 0 0 #DIV/0!

9. 0 0 0 #DIV/0!

10. 0 0 0 #DIV/0!

11 0 0 0 #DIV/0!

12 0 0 0 #DIV/0!

13 0 0 0 #DIV/0!

14 0 0 0 #DIV/0!

15 0 0 0 #DIV/0!

16 0 0 0 #DIV/0!

17 0 0 0 #DIV/0!

18 0 0 0 #DIV/0!

19 0 0 0 #DIV/0!

20. 0 0 0 #DIV/0!

21 Others 0 0 0 #DIV/0!

Total 0 0 0 0 0 0 0 0 0 0 0 xxx
 16

3 HOSPITAL OPERATIONS (Cont.)

3.8.4 Hospital Infection Rate (Nosocomial Infection)
3.8.4.1 Gross Infection Rate %
*Gross Infection Rate = Total no. of infection in the hospital (ward) for a period *100
Total discharges and death from hospital (ward) for the same period

3.8.4.2 Net Infection Rate %

*Net Infection Rate = Total no. of infection debited against the hospital (ward) *100
Total discharges and death from hospital (ward) for the same period

3.9 Surgical Operations

3.9.1 Surgical Operation (Pediatrics)
Number of Patients
Pay Service
Type of Operations PHIC HMO PHIC
Non Non % of Grand
PHIC Mem/Dep Indigent w/ PHIC w/o PHIC OWWA PHIC Mem/Dep Indigent OWWA Total Total
1 Major Operations (Excl. Caesarian) 0 #DIV/0!
2 Caesarian Operation 0 #DIV/0!
3 Minor Operations (In-Patients) 0 #DIV/0!
4 Minor Operations (Out-Patients) 0 #DIV/0!
5 Minor Operations (ER) 0 #DIV/0!
TOTAL: 0 0 0 0 0 0 0 0 0 0 0

3.9.2 Surgical Operation (Medicine)

Number of Patients
Pay Service
Type of Operations Non PHIC HMO Non PHIC % of Grand
PHIC Mem/Dep Indigent w/ PHIC w/o PHIC OWWA PHIC Mem/Dep Indigent OWWA Total Total
1 Major Operations (Excl. Caesarian) 0 #DIV/0!
2 Caesarian Operation 0 #DIV/0!
3 Minor Operations (In-Patients) 0 #DIV/0!
4 Minor Operations (Out-Patients) 0 #DIV/0!
5 Minor Operations (ER) 0 #DIV/0!
TOTAL: 0 0 0 0 0 0 0 0 0 0 0

3.10 Leading Major Operations

Number of Patients
Pay Service
Procedures Non PHIC HMO Non PHIC % of Grand
PHIC Mem/Dep Indigent w/ PHIC w/o PHIC OWWA PHIC Mem/Dep Indigent OWWA Total Total
1 0 #DIV/0!
2 0 #DIV/0!
3 0 #DIV/0!
4 0 #DIV/0!
5 0 #DIV/0!
6 0 #DIV/0!
7 0 #DIV/0!
8 0 #DIV/0!
9 0 #DIV/0!
10 0 #DIV/0!
11 Others 0 #DIV/0!
Grand Total : 0 0 0 0 0 0 0 0 0 0 0

3.11 Leading Minor Operations

Number of Patients
Pay Service
Procedures Non PHIC HMO Non PHIC % of Grand
PHIC Mem/Dep Indigent w/ PHIC w/o PHIC OWWA PHIC Mem/Dep Indigent OWWA Total Total
1 0 #DIV/0!
2 0 #DIV/0!
3 0 #DIV/0!
4 0 #DIV/0!
5 0 #DIV/0!
6 0 #DIV/0!
7 0 #DIV/0!
8 0 #DIV/0!
9 0 #DIV/0!
10 0 #DIV/0!
11 Others 0 #DIV/0!
 17

Grand Total 0 0 0 0 0 0 0 0 0 0 0
 17

4 ER SERVICES
4.1 Total No. of Patients Attended: New : Revisit : Total :
4.2 Classification of ER Patients: Emergency : Non-emergency : Total :
4.3 Average Number of ER Patients per Day ---------------------------> :
4.4 Twenty Leading Causes of Emergency Cases in the ER Department

Age Distribution of Patients

Total
<1 1-4 5-9 10-14 15-19 20-44 45-64 >=65 ICD10
# Diagnosis (Primary) % of Total Total Cost Tab No
M F M F M F M F M F M F M F M F M F T

1 0 0 0 #DIV/0!
2 0 0 0 #DIV/0!
3 0 0 0 #DIV/0!
4 0 0 0 #DIV/0!
5 0 0 0 #DIV/0!
6 0 0 0 #DIV/0!
7 0 0 0 #DIV/0!
8 0 0 0 #DIV/0!
9 0 0 0 #DIV/0!
10 0 0 0 #DIV/0!
11 0 0 0 #DIV/0!
12 0 0 0 #DIV/0!
13 0 0 0 #DIV/0!
14 0 0 0 #DIV/0!
15 0 0 0 #DIV/0!
16 0 0 0 #DIV/0!
17 0 0 0 #DIV/0!
18 0 0 0 #DIV/0!
19 0 0 0 #DIV/0!
20 0 0 0 #DIV/0!
21 Others 0 0 0 #DIV/0!
 18

Age Distribution of Patients

Total
<1 1-4 5-9 10-14 15-19 20-44 45-64 >=65 ICD10
# Diagnosis (Primary) % of Total Total Cost Tab No
M F M F M F M F M F M F M F M F M F T

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 18

4 ER SERVICES (Cont.)

4.5 Twenty Leading Causes of Non-Emergency Cases in the ER Department

Age Distribution of Patients

Total
<1 1-4 5-9 10-14 15-19 20-44 45-64 >=65 % of ICD10
# Diagnosis (Primary) Total Cost
Total Tab No
M F M F M F M F M F M F M F M F M F T

1 0 0 0 #DIV/0!
2 0 0 0 #DIV/0!
3 0 0 0 #DIV/0!
4 0 0 0 #DIV/0!
5 0 0 0 #DIV/0!
6 0 0 0 #DIV/0!
7 0 0 0 #DIV/0!
8 0 0 0 #DIV/0!
9 0 0 0 #DIV/0!
10 0 0 0 #DIV/0!
11 0 0 0 #DIV/0!
12 0 0 0 #DIV/0!
13 0 0 0 #DIV/0!
14 0 0 0 #DIV/0!
15 0 0 0 #DIV/0!
16 0 0 0 #DIV/0!
17 0 0 0 #DIV/0!
18 0 0 0 #DIV/0!
19 0 0 0 #DIV/0!
20 0 0 0 #DIV/0!
21 Others 0 0 0 #DIV/0!
 19

Age Distribution of Patients

Total
<1 1-4 5-9 10-14 15-19 20-44 45-64 >=65 % of ICD10
# Diagnosis (Primary) Total Cost
Total Tab No
M F M F M F M F M F M F M F M F M F T

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 19

5 OUT-PATIENT SERVICES

5.1 Out-Patient Demographic Data by Congressional Districts

Number of Patients

Pay Service
Districts
PHIC HMO PHIC
Non OWW Non OWW % of Grand
PHIC Member/Dep Indigent w/ PHIC w/o PHIC A PHIC Member/Dep Indigent A Total Total

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

0 #DIV/0!

Grand Total 0 0 0 0 0 0 0 0 0 0 0

5.2 Total No. of Patients Attended: New : Revisit : Total : -

5.3 Average Number of Out-Patients per Day : patients

5.4 Number of Encounters : (5.2 minus 5.1)

5.5 Number of OPD Admission :

5.6 Services Rendered in the Out-Patient Department:

Number of Patients Attended/Served

Type of Service % of Total
New Revisit Total

Medical 0 #DIV/0!
Obstetrics 0 #DIV/0!
Gynecologcy 0 #DIV/0!
Pediatrics 0 #DIV/0!
Surgery 0 #DIV/0!
Others (Specify) 0 #DIV/0!
EENT 0 #DIV/0!
Dental 0 #DIV/0!
Family Planning 0 #DIV/0!
TOTAL: 0 0 0 #DIV/0!
 20

5 OUT-PATIENT SERVICES (Cont.)

5.7 Twenty (20) Leading Causes of Consultations at OPD

Age Distribution of Patients

Total
<1 1-4 5-9 10-14 15-19 20-44 45-64 >=65 ICD10
# Cause of Consultation (Primary) % of Total Total Cost Tab No
M F M F M F M F M F M F M F M F M F T

1 0 0 0 #DIV/0!
2 0 0 0 #DIV/0!
3 0 0 0 #DIV/0!
4 0 0 0 #DIV/0!
5 0 0 0 #DIV/0!
6 0 0 0 #DIV/0!
7 0 0 0 #DIV/0!
8 0 0 0 #DIV/0!
9 0 0 0 #DIV/0!
10 0 0 0 #DIV/0!
11 0 0 0 #DIV/0!
12 0 0 0 #DIV/0!
13 0 0 0 #DIV/0!
14 0 0 0 #DIV/0!
15 0 0 0 #DIV/0!
16 0 0 0 #DIV/0!
17 0 0 0 #DIV/0!
18 0 0 0 #DIV/0!
19 0 0 0 #DIV/0!
20 0 0 0 #DIV/0!
21 Others 0 0 0 #DIV/0!
 21

5 OUT-PATIENT SERVICES (Cont.)

5.7 Twenty (20) Leading Causes of Consultations at OPD

Age Distribution of Patients

Total
<1 1-4 5-9 10-14 15-19 20-44 45-64 >=65 ICD10
# Cause of Consultation (Primary) % of Total Total Cost Tab No
M F M F M F M F M F M F M F M F M F T

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 22

5 OUT-PATIENT SERVICES (Cont.)

5.8 Immunization (include those performed for in-patients and out-patients)
Number of Patients
Pay Service % of Grand
Immunization Total
Total
Non PHIC HMO PHIC
OWWA Non PHIC OWWA
PHIC Member/Dep Indigent w/ PHIC w/o PHIC Member/Dep Indigent
DPT 1 0
DPT 2 0
DPT 1 0
DPT 2 0
DPT 3 0
BCG 0
Measles 0
Tetanus Toxoid 1 0
Tetanus Toxoid 2 0
Hepatitis A 0
Hepatitis B1 0
Hepatitis B2 0
Hepatitis B3 0
Polio 1 0
Polio 2 0
Polio 3 0
Rabies 0
- Active 0
- Passive 0
Others (specify) 0
Grand Total
5.9 No. of Fully Immunized Children
6 OTHER HOSPITAL SERVICES
6.1 Laboratory Service
Number of Patients
Pay Service % of Grand
Procedures PHIC HMO PHIC Total
Non Total
OWWA Non PHIC OWWA
PHIC Member/Dep Indigent w/ PHIC w/o PHIC Member/Dep Indigent
Laboratory Examination
1. Clinical Pathology 0
1.1 Clinical Microscopy 0
1.1.1 Routine Urinalysis 0
1.1.2 Special Urinalysis 0
1.1.3 Routine Fecalysis 0
1.1.4 Special Fecalysis 0
1.2 Hematology 0
1.2.1 Routine Hematology 0
1.2.2 Special Hematology 0
1.3 Clinical Chemistry 0
1.3.1 Routine Chemistry 0
1.3.2 Special Chemistry 0
1.4 Blood Banking 0
1.5 Immunology/Serology/HIV 0
1.6 Microbiology 0
1.6.1 Smears 0
1.6.2 Culture & sensitivity 0
1.7 Environmental Health 0
1.8 Assay 0
1.8.1 Assay of drugs 0
1.8.2 Assay of food 0
2. Anatomic Pathology 0
2.1 Basic histopathology 0
2.2 Special stains 0
2.3 Immunohistochemistry 0
6.2 Radiological Service
Number of Patients
Pay Service % of Grand
Procedures PHIC HMO PHIC
Total
Total
Non
OWWA Non PHIC OWWA
PHIC Member/Dep Indigent w/ PHIC w/o PHIC Member/Dep Indigent
X-ray 0
Routine 0
Special 0
Ultrasound 0
C.T. Scan 0
M.R.I. 0
TOTAL: 0 0 0 0 0 0 0 0 0 0 0
 23

6 OTHER HOSPITAL SERVICES

6.3 Dietary Service

6.3.1 No. of persons subsidized

Philhealth Pay Service Employee Guest Total

In Patient 0

Out Patient 0

ER Patients 0

Others 0

Total 0 0 0 0 0 0

6.3.2 No. of meals served:

6.3.2.1 Routine Diets
6.3.2.2 Therapeutic Diets

6.3.2.2.1 Enteric Feeding

6.3.2.2.2 Others

6.3.3 No. patients given diet counselling

6.3.3.1 In Patients % of Total In Patients #DIV/0!
6.3.3.2 Out Pateints % of Total Out Patients #DIV/0!
6.3.3.3 ER Pateints % of Total ER Patients #DIV/0!
6.3.3.4 Others
Total: 0

6.4 Pharmacy Service

6.4.1 In-Patient
Philhealth Pay Service Employee Total

Presciption Filled 0

Presciption Unfilled 0
Prescription bought outside by
0
hospital thru emergency purchase
Total 0 0 0 0 0

6.4.2 Out-Patient
Philhealth Pay Service Employee Total

Presciption Filled 0

Presciption Unfilled 0

Total 0 0 0 0 0

6.4.3 ER Patients
Philhealth Pay Service Employee Total
Presciption Filled 0
Presciption Unfilled 0

Total 0 0 0 0 0
 24

6.5 Medical Social Service

6.5.1 Patients Served

Class

C Bgry Total
A B D Veteran Sr. Citizen Official/
BHW
1 2 3
1. In Patients 0
2. Out Patients 0
3. ER Patients 0

4. Others 0
Total 0 0 0 0 0 0 0 0 0 0

6.5.2 10 Leading Reasons for Psychosocial Counselling

Reasons Number

1
2

7
8

10

6.5.3 Intensive Case Work

Number of Abandoned Patients Total

Pedia Adult Total Number of abused women

Number of abused children

0
Number of abused men

6.6 Other Ancillary Procedures

Total
Personnel/
Philhealth Pay Service
Employee
In-Patient % Out-Patient %

ECG
Echocardiogram

Others:
TOTAL 0 0 0 0 0 0
 25

6.7 Referrals

6.8 Other Activities Performed Total # of Trips

6.8.1 Hospital Transport Services
6.8.1.1 Ambulance calls/conduction
6.8.1.2 Other hospital vehicles

6.8.2 Autopsies Performed

6.8.2.2 Partial
6.8.2.3 Gross
6.8.2.4 Microscopic
6.8.2.5 No. of cases requiring autopsy
6.8.3 Medico Legal
6.8.3.1 Number of medico-legal cases
6.8.3.2 Number of medico-legal deaths
6.8.3.3 Number of court appearances

7 STAFFING PATTERN
7.1 Personnel/Staff Assignment

Number of Personnel (Authorized)

Medical Nursing
Consultants MW/ Admin Total
Res Ancillary Dental Head Supervisor Staff HEPO
Part Time Full Time Aide

7.2 Administrative Service 0 0 0

Authorized Actual/Implementing Full Time Equivalent
26
 26

8. Manpower Development

8.1 Training Programs (Administrative, Nursing, Medical, Ancillary, etc.)

Title of Training Programs Conducted By (Agency/Institution) Inclusive Dates

8.2 Research Conducted

Conducted By

Title of Research (Whom/Agency/Institution) Inclusive Dates

9. Committees
EXISTING FUNCTIONAL
YES NO YES NO REMARKS
9.1 Technical
9.1.1 Medical Audit
9.1.2 Clinical Conference
9.1.3 Infection Control Committee
9.1.4 Pharmaceutical/Therapeutic
9.1.5 Tissue Committee
9.1.6 Journal Committee (Nursing)
9.1.7 Medical Records Committee
9.1.8 Utilization Review
9.1.9 Accreditation Committee
9.1.10 Tumor Board
9.1.11 Waste Management Credential Committee
9.2 Administrative
9.2.1 Bidding and Awards Committee
9.2.2 Records Management Committee
9.2.3 Finance Committee
9.2.4 Medical Library Committee
9.3 Others
 27

9. Committees
EXISTING FUNCTIONAL
YES NO YES NO REMARKS
 27

10. FINANCIAL DATA (in Pesos)

10.1 Total Budget requested for the year

10.2 Total Budget released for the year
10.3 Total Income for the year

10.3.1 In-Patient Charges - Medical

10.3.1.1 Service Participations
10.3.1.2 Philhealth
10.3.1.3 Charges of Paying Patients
10.3.1.4 Other sources

10.4 Total Expenditures (in Pesos)

10.4.1 Personnel Expenditures

10.4.1.1 Salaries
10.4.1.2 Wages
10.4.1.3 GSIS Remittance
10.4.1.4 Maternity Leave Benefits
10.4.1.4 Philhealth Contributions
10.4.1.5 Pag-ibig Contributions
10.4.1.6 Clothing Allowance
10.4.1.7 Others

10.4.2 Direct Patient Care

10.4.2.1 Cost of subsistence
10.4.2.2 Laundry allowance
10.4.2.2 Surgical/medical supplies
10.4.2.3 Laboratory supplies
10.4.2.4 Radiology supplies
10.4.2.5 Dental
10.4.2.6 Medicines
10.4.2.6.1 Revolving Fund
10.4.2.6.2 G.O.P.

10.4.3 Overhead or other operating expenses

10.4.3.1 Travelling expenses
10.4.3.2 Training Seminar
10.4.3.3 Rentals
10.4.3.4 Water
10.4.3.5 Power and light service
10.4.3.6 Postal and telephone service
10.4.3.7 Repair of building and maintenance
10.4.3.8 Repair of equipment
10.4.3.9 Repair of vehicles
10.4.3.10 Gasoline, oil and lubricants
10.4.3.11 Miscellaneous (Supplies/Materials)
10.4.3.12 Other expenses
10.4.3.13 Amortization
 28

10.4.4 Capital Outlay

10.4.4.1 Capital Outlay
10.4.4.2 Purchase of Equipment

10.5 Cost analysis based on alloted MOOE

10.5.1 In-Patient
10.5.1.1 Cost/Bed Day -
10.5.1.2 Cost of Medicine/Bed Day -
10.5.1.3 Cost of Medical Supplies/Bed Day -
10.5.1.4 Cost of Food/Bed Day -
10.5.2 ER Patient
10.5.2.1 Cost of ER Patient
10.5.2.2 Cost of ER Medicine/Patient
10.5.2.3 Cost of ER Medical Supplies/Patient
10.5.3 OPD Patient
10.5.3.1 Cost of Consultation/Patient
10.5.3.2 Cost of Supplies/Patient

10.6 Distribution of Treatment Cost by Responsibility

10.6.1 Philhealth
10.6.2 Hospital Subsidy (Quantified Free Service)
10.6.3 Out of Pocket (Patients’ Payment/Participation)
10.6.4 Donors (Funds from PCSO, PDAF or other Philantrophic Agencies or Individuals)
10.6.5 Other Sources

10.7 Programs implemented e.g. Hospitals as Centers of Wellness, HIC, QAC, etc.

Programs Accomplishments Issues & Concerns

Prepared by:

Statistician/Statistician Designate

Submitted by:

Records Officer

Date: