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 [ ] General

[ ] Level 1/Infirmary [ ] Special, Specify ___________
[ ] 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: Private:
[ ] National – DOH Retained/Renationalized [ / ] Single Proprietorship/Partnership/Corp.
[ ] Local [ ] Religious
[ ] Other Government Agency, specify ____________ [ ] Foundation

2. Quality Management:
[ ] Certified ISO, Specify _________ Validity Period _________________
[ ] PCAHO Validity Period _________________
[ ] Other Certifying Body, Specify ________________ Validity Period _________________
3 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
REMARKS
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
6. Other Facility/Service available

EXISTING
FACILITY REMARKS
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. Financial Status
7.1 Total Budget __________
7.2 Total Income __________
7.3 Total Expenditure __________
2.3Ten (10) Leading Causes of Discharges (Morbidity)

Discharge Age Distribution of Patients

TOTAL ICD-10
Diagnosis Under 1-4 5-9 10-14 15-19 20-44 45-64 =>65 CODE/
(Primary) 1 TABULATION
No M F M F M F M F M F M F M F M F M F T LIST
Abbreviation
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 Age Distribution of Patients

TOTAL ICD-10
Diagnosis Under 1-4 5-9 10-14 15-19 20-44 45-64 =>65 CODE/
(Underlying) 1 TABULATION
No M F M F M F M F M F M F M F M F M F T LIST
Abbreviation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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

=<19 y.o. => 20 y.o. ALL AGES

Types of operations
MALE FEMALE MALE FEMALE MALE FEMALE TOTAL
Major Operation
(excl.CS)
Caesarian Operation xxxxxx xxxxxx xxxxxx
Minor Operation
(In-Pt)
Minor Operation
(Out-Pt)

6 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 Causes No. of Consultation

1. 6.
2. 7.
3. 8.
4. 9
5. 10.

7. OUT –PATIENTS SERVICES

7.1 Total No. of Patients attended: New: 167 Re-visit: 27 Total: 194
7.2 Average Number of Out –patient per day: 2.12%
7.3 Ten (10) Leading Causes of Consultations at OPD

Causes No. of Consultation Causes No. of Consultation

1. 6.
2. 7.
3. 8.
4. 9.
5. 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 Date: ___________

Chief of Hospital/Medical Director

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