Type Of Accommodation

Type of Service

Medicine
Obstetrics
Gybecology
Pediatrics
Surgery
Pedia
Adult
Othes,Specify
Total
Total Newborn
Pathologic
Non-Patho

No. of Pts

Non-Philhealth
Total Length
of Stay
/Total no. of
days stay

P
a
y

Service
Charity

Philhealth

Total

P
a
y

Type Of Accommodation

Condition on Dis

Philhealth
Total

Service

Member/Dependent

Indigent

H
M
O

O
W
W
A

R
/
I

Condition on Discharge

Deaths

Total
Discharge
<48

48

Total

Cause of Morbidity(underlying)
under 1
Spell out . Do not abbreviate

1 to 4
F

5 to 9
F

5 to 9

10 to 14
F

15 - 19
F

20-24
F

25-29
F

Age Distribution of Patients

30-34
35-39

25-29
F

40-44
F

45-49
F

45-49

50-54
F

55-59
F

60-64
F

65-69
F

subTotal
65-69

Total

70 & over
F

ICD-10 Code/Tabular List

Cause of Death(underlying)
under 1
Spell out . Do not abbreviate

1 to 4
F

5 to 9
F

5 to 9

10 to 14
F

15 - 19
F

20-24
F

25-29
F

Age Distribution of Patients

30-34
35-39

25-29
F

40-44
F

45-49
F

45-49

50-54
F

55-59
F

60-64
F

65-69
F

subTotal
65-69

Total

70 & over
F

ICD-10
Code/Tabu
lar List

Proffesion/Position/Designati
on

Total Staff Working Full Time (atleast 40 houra/week

Number of
Permanent Staff
A. Medical
1. Consultants ( indicate one peso
consultant
1.1 Internal Medicine
a. Generalist
b. Cardiologist
c. Endocrinologist
d. Gastro-Enterologist
e. Pumonologist
f. Nephro;ogist
g. Neurologist
h. Others(Specify)
1.2 Obstetrics/Gynecology (and
Subspecialty
1.3 Pediatrics (and subspecialty)
1.4 Surgery
1.5 Anesthesiologist
1.6 Radiologist
1.7 Pathologist
2. Post-Graduate Fellows
(indicate Specialty/subspecialty)
3. Resident
3.1 Internal Medicine
3.2 Obstetrics/Gynecology
3.3 Pediatric
3.4 Surgery
3.5 Others (Specify)
b. Allied Medicine
!. Nurses
2. Midwives
3. Nursing Aides
4. Nutritionist
5. Physical Therapists

Number of
Contractual Staff

Number of
Volunteer Staff

6. Pharmacists
7. Medical Technologist
8. Others (specify)
C. Non-Medical
1. Social Worker
2 Medical Records Officer/Hospital
Health Information Officer with
training in medical records
management
3.
4.
5.
6.

Laboratory Technicians
X-ray Techniciana
Administrative Officer
Accounting/Finance Officer
7. General Services Staff
( Maintenance, Janitorial,
secretarial) indicate if outsourced

40 houra/week

Number of
Volunteer Staff

Total staff working part time (at least 20 hours/week)

Number of
Permanent Staff

Number of
Contractual Staff

Number of
Volunteer Staff

Active Rotating or
Visiting/Affiliate
(For Private
Facilities

Active Rotating or
Visiting/Affiliate
(For Private
Facilities

Outsourced