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Acute Chronic Psychiatric Care Facility
DOH assessment tool for licensing an acute - chronic psychiatric care facility
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Health
Manila
OTHER HEALTH FACILITIES (BIRTHING HOME/PSYCHIATRIC CARE FAC.)
STATISTICAL REPORT
For the Year _______
StatForm2
Name of Health Facility:________________________ Complete Address: _____________________________
Region: _______
Contact No.______________
Fax No. ____________ E-mail Address _____________
( PLEASE FILL-UP ALL ITEMS, N/A IF NOT APPLICABLE )
I. GENERAL INFORMATION
1. Classification:
1.1. Service Capability, Check if:
[ ] Birthing Home
[ ]
Acute-Chronic Psychiatric Care Facility
[ ]
Custodial Psychiatric Care Facility
1.2. Nature of Ownership:
Government :
[ ] National – DOH Retained/Renationalized
[
2.
]
] Local
[
Private: [
] Other Government Agency, specify ____________
Bed Capacity/Occupancy:
2.1
Authorized Bed Capacity ________beds
2.2
2.3
3.
Actual/Implementing Beds _______beds
Bed Occupancy Rate (BOR)
2.3.1 Based on Authorized Beds
______%
Total In-patient service days for the period *
(Total no. of authorized beds) x (Total days in the period)
Number of Personnel
PERSONNEL
Permanent
Actual No. of Personnel
Contractual
TOTAL
Medical Specialist/Consultant
Physician
Psychiatrist
Psychologist
Recreational Therapist
Nurse
Nursing Attendant
Midwife
Others, Specify ___________
1
x 100
4. Programs (for Birthing Home)
Health Promotion and Disease Prevention
A. Breastfeeding
B. Newborn Screening (fully implemented
by year 2006)
C. Rooming-In
D. Family Planning
E. Immunization
5.
II.
Financial Status
5.1
Total Budget
5.2
Total Income
5.3
Total Expenditure
EXISTING
No
Yes
REMARKS
_____________________________
_____________________________
_____________________________
HEALTH FACILITY OPERATIONS
1. Summary of Patients in the Health Facility:
1.1 Patients remaining in the facility as of midnight last day of
previous month/year
1. 2 Total Admission
1. 3 Total Discharges (Alive )
1. 4 Total In-patients deaths
1. 5 Total Patients Admitted and Discharged the same day
1. 6 Total In-Patients Service Days for the period *
_______
_______
_______
_______
_______
_______
1. 7 Average Daily Census of Admitted Patients
Total in-patient service days for the period *
Total days in the period
_______
1.8 Referrals (In-patient)
1.8.1 from RHU/centers
1.8.2 from other hospitals/centers
1.8.3 to other health facilities/hospitals
__________
__________
__________
2. DISCHARGES
2.1 Services rendered and patients attended:
Type of Accommodation
Type
of
Service
No
of
Pts.
Total
Length
of
Stay/
Total
No. of
Days
Stay
Non-PhilHealth
Condition on Discharge**
PhilHealth
H
M
O
Service
Pay
Service
Charity
O
W
W
A
R/
I
T
H
A
U
Total
Pay
Total
Member/
Depdnt
Indig.
Obstetrics
Psychiatric
Custodial
Others,
Specify
Total
Newborn
(born alive)
rooming-in
** R/I – Recovered/Improved
H- Home Against Medical Advice
T- Transferred
A – Absconded
2
U - Unimproved
D – Died (died upon admission)
Died
<48
hrs.
Died
=> 48
hrs.
Total
2.2 Average Length of Stay (ALOS) of Admitted Patients
Total Length of stay of discharged patients (incl. Deaths) in the period
Total discharges and deaths in the period
_______
2.3. Ten (10) Leading Causes of Discharges (Morbidity)
Discharge Diagnosis
(Primary )
No Abbreviation
Distribution of Patients by Sex
Male
Female
ICD-10
CODE
Total
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
3. DEATHS
Ten (10) Leading Causes of Deaths (Mortality )
Cause of Death
(Underlying )
No Abbreviation
Distribution of Patients by Sex
Male
Female
ICD-10
CODE
Total
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
III.
OUT-PATIENT SERVICES (N/A IF NOT APPLICABLE)
1. Total No. of Patients attended :
New ________
2. Average Number of Out-patient per day:
________
3. Ten (10) Leading Causes of Consultations at OPD
Causes
No. of Consultation
Re-visit ______ Total _________
Causes
1.
2.
3.
4.
5.
No. of Consultation
6.
7.
8.
9.
10.
Prepared by
: ________________________________
Designation/Section or Dept.
: ________________________________
APPROVED & CERTIFIED BY: ____________________________
Head of Facility
c:f/forms/ statform2bhompsch.doc/1105
3
Date: _______
Date: _____
DEFINITION OF TERMS :
1. Service Capability - Capability of the hospital/other health facility to render administrative,
clinical, ancillary and other services
3. Hospital bed
- Bed which is maintained for continuous (24 hours) use by an in-patient
4. Bed Occupancy Rate - The percentage of in-patients beds occupied over a period of time. It is
a measure of the intensity of hospital resources utilized by in-patients.
5. Authorized bed
- Approved number of beds as per issued license to operate in the hospital
and other health facilities.
6. Implementing beds
- Actual beds use (based on hospital/facility management decision)
7. In-Patient Service days- Unit of measure denoting the services received by one in-patient in one
24 hours period.
8. Average Number of In-patients per day - Average no. of in-patients present each day for a
given period of time.
9. Total Length of Stay -( for one In-patient)- The number of calendar days from admission to
discharge.
10. Average Length of Stay- Average no. of days each in-patient stays in the hospital for each
episode of care.
17. ICD-10 Code
- an International Statistical Classification of Diseases and Related Health
Problems (10th revision) published by WHO. Administrative Order
No. 47s., 2000 dated May 5, 2000, DOH stated that ICD-10 coding shall be
fully implemented in all government and private hospitals starting January
2001 to improve the quality of morbidity and mortality statistics.
18. NON-PHILHEALTH - A type of accommodation that pertains to patients without PhilHealth
Insurance. This is further subdivided to Pay and Service or Charity.
19. PHILHEALTH
- A type of accommodation that pertains to patients with PhilHealth Insurance.
This is further subdivided into Pay and Service or Charity.
a. PAY Patients confined in the pay wards or private rooms
b. ServicePatients confined in the service wards which used to be called Charity ward
b.1 IndigentPatient under the service care who is enrolled PHIC indigent as validated
by a PHIC Indigent Card/GMA Card.
b.2 Member/Dependent – Patient under the service care with mandatory or voluntary PHIC
membership or is a dependent of said member.
20. OWWA acronym for Overseas Workers Welfare Administration, which provides health/
hospitalization insurance of the overseas workers and their dependents.
21. HMO acronym for Health Maintenance Organization which provides medical/hospitalization
insurance to Policyholders.
4
TYPE OF HEALTH FACILITY __________________________ GOVT ____ PVT_____
STATISTICAL REPORT, JANUARY-DECEMBER ____________
SERVICES
1. BED CAPACITY AND OCCUPANCY:
1.1 Authorized Bed Capacity (ABC)
1.2 Actual/Implementing Beds
1.3 Bed Occupancy Rate (based on authorized beds);
*Total In-patient service days ÷
( No. ABC ) x (Total days in the period) x 100
2. HEALTH FACILITY OPERATIONS
2.1. Summary of Patients in the Health Facility:
2.1.1 Total Admission (excluding Newborn)
2.1.2 Number Newborn
2.1.3 Total Discharges (Alive)
2.1.4 Total In-patient Deaths
2.1.5 Total Patients Admitted and Discharge the same day
2.1.6 Total In-patient service days*
2.1.7 Average Daily Census of Admitted Patients:
*Total In-patient service days ÷ Total days in the period
2.1.8 Referrals ( check if existing )
-from RHU
-from hosp.
- to other health fac./hosp.
2.2. Discharges:
2.2.1 Services rendered and patients attended:
ACCOMPLISHMENT
No. of
Patients
Total Length of
Stay/No. of Days
Stay
Medicine
Obstetrics
Gynecology
Pediatrics
Surgery
Others:
TOTAL
Newborn (born Alive)
ACCOMPLISHMENT
2.2.2 Average length of stay of admitted patients:
Total length of stay of discharge patients including deaths ÷
Total discharges and deaths in the period
2.2.3 Number died under 48 hours including newborns
2.2.4 Number died beyond 48 hours including newborns
2.2.5 No. of deliveries:
Normal
Caesarian
Others
3. OUT-PATIENT SERVICES
3.1 Total No. of Patients Attended:
- New
3.2 Average no. of out-patient/day
4. E R SERVICES
4.1 Total No. of Patients Attended:
4.2 Average no. of ER cases/day
5. TOTAL SURGICAL OPERATIONS
MAJOR
MINOR
5
6. NO. OF PERSONNEL (ACTUAL )
6.1 No. Physician *
6.2 No. Psychiatrist
6.3 No. Psychologist
6.4 No. Staff Nurse
6.5 No. Chief Nurse
6.6 No. Supervising Nurse
6.5 No. Nursing Attendant
6.6 No. Midwife
7. FINANCIAL STATUS
7.1 Total Budget
7.2 Total Income
7.3 Total Expenditures
NO.
EXISTING
FAC./SERV.
8. OTHER FACILITY/SERVICE AVAILABLE
1. BLOOD BANK
2. BLOOD COLLECTION UNIT/BLOOD STATION
3. DIALYSIS CLINIC
4. DRUG TESTING LAB.
5. HIV TESTING LAB.
6. MEDTECH INTERN TRAINING LAB.
7. REHABILITATION CENTER
8. WATER TESTING LAB.
9. NEWBORN SCREENING CTR.
10. KIDNEY TRANSPLANT FACILITY
11. AMBULATORY SURGICAL CLINIC
9. DEATHS
1. NO. FOETAL DEATHS (less than 22 completed weeks or <500g b.w.
2. NO. FOETAL DEATHS (22 weeks or more compl. Wks or >500g. b.w.
3. NO. NEONATAL DEATHS ( less than 28 days)
4. NO. INFANT DEATH ( less than 1 yr.)
6. NO. MATERNAL DEATH ( within 42 days after term. pregnancy)
7. NO. E R DEATHS
8. NO. DEAD ON ARRIVAL
6
TYPE OF FACILITY _______________
TOTAL NO. OF HOSPITALS W/ REPORT ______
TOTAL NO. OF DISCHARGES________
TOTAL NO. OF NSD ___________
GOV’T.______
PVT. ________
TOTAL ABC _________
10. TEN LEADING CAUSES OF DISCHARGES – Discharge Diagnosis
Disease ( No Abbreviations)
1.
2.
3.
4.
6.
7.
8.
9.
10.
11. TEN LEADING CAUSES OF DEATHS- Underlying Cause of Death
Disease ( No Abbreviations)
1.
2.
3.
4.
6.
7.
8.
9.
10.
Number
ICD-10 Code
Number
ICD-10 Code
TYPE OF FACILITY _______________
GOV’T.______
PVT. ________
TOTAL NO. OF HOSPITALS W/ REPORT ______
TOTAL ABC _________
TOTAL NO. OF OPD _____________ NEW _______
REVISIT ___________
12. TEN LEADING CAUSES OF CONSULTATIONS (OPD)
Disease ( No Abbreviations)
Number
1.
2.
3.
4.
6.
7.
8.
9.
10.
TYPE OF FACILITY _______________
TOTAL NO. OF HOSPITALS W/ REPORT ______
TOTAL NO. OF ER CASES_____________
13. TEN LEADING E R CASES
CAUSES
1.
2.
3.
4.
5.
GOV’T.______
PVT. ________
TOTAL ABC _________
NO. OF CASES
CAUSES
6.
7.
8.
9.
10.
7
NO. OF CASES
DEFINITION OF TERMS :
2. Service Capability - Capability of the hospital/other health facility to render administrative,
clinical, ancillary and other services
3. Quality Management/Quality Assurance Program - Organized set of activities designed to
demonstrate on-going assessment of important aspects of patient care and services.
3. Hospital bed
- Bed which is maintained for continuous (24 hours) use by an in-patient
4. Bed Occupancy Rate - The percentage of in-patients beds occupied over a period of time. It is
a measure of the intensity of hospital resources utilized by in-patients.
5. Authorized bed
- Approved number of beds as per issued license to operate in the hospital
and other health facilities.
6. Implementing beds
- Actual beds use (based on hospital/facility management decision)
7. In-Patient Service days- Unit of measure denoting the services received by one in-patient in one
24 hours period.
8. Average Number of In-patients per day - Average no. of in-patients present each day for a
given period of time.
9. Total Length of Stay -( for one In-patient)- The number of calendar days from admission to
discharge.
10. Average Length of Stay- Average no. of days each in-patient stays in the hospital for each
episode of care.
11. Spontaneous Abortion - without intervention
12. Induced Abortion
- with intervention
13. Septic
- with infection
14. Non-Septic
- without infection
15. Major Operation
- Surgical procedures requiring anesthesia/spinal anesthesia to be
performed
in an operating theatre
16. Minor operations - Surgical procedures requiring only local anesthesia/no OR needed example
suturing.
17. ICD-10 Code
- an International Classification of Diseases version 10. Administrative Order
No. 47s., 2000 dated May 5, 2000, DOH stated that ICD-10 coding shall be
fully implemented in all government and private hospitals starting January
2001 to improve the quality of morbidity and mortality statistics.
18. NON-PHILHEALTH - A type of accommodation that pertains to patients without PhilHealth
Insurance.
This is further subdivided to pay and Service or Charity.
19. PHILHEALTH
- A type of accommodation that pertains to patients with PhilHealth Insurance.
This is further subdivided into pay and service or charity.
PAY
Patients confined in the pay wards or private rooms
ServicePatients confined in the service wards which used to be called Charity ward
MemberThe policyholder of PhilHealth Insurance who was confined in the service ward.
Dependent- Refers to dependents of PhilHealth Insurance member confined in the service
ward.
IndigentThe beneficiaries of the Indigent Program of PhilHealth which used to be called
Medicare para sa Masa Program. Their premiums were either solely paid by the
Local government or with support from the national government. They are issued
Identification Cards which are called GMA Cards.
NOTE: The principle behind identifying these three last groupings is to have a
clearer picture of who is responsible for the treatment cost of the patients.
20. OWWA -
acronym for Overseas Workers Welfare Administration, which provides health/
hospitalization insurance of the overseas workers and their dependents.
8
21. HMO
acronym for Health Maintenance Organization which provides
medical/hospitalization insurance to Policyholders
22. Categorization of Patients : ( for availment of social services in hospitals)- Department Order
No.435 s., 1990
a. Class A – Pay
Patients shall pay in full the hospital services in suites, private or semi-private rooms.
PhilHealth patients/other health insurance shall pay the excess of their privelege in full.
b. Class B – Pay Ward ( 3 beds and above)
Patients shall pay the hospital services on the ward level. PhilHealth patients/other health
insurance shall pay the excess of their privelege in full.
c. Class C – Service PhilHealth; partial sharing:donation
Patients with PhilHealth benefits/other health insurance but cannot pay the excess in full.
Patient’s share of the balance after health insurance shall be in accordance with C1, C2, or C3
sub-classification, as affected by modifiers.
C1 - patients whose aggregate monthly family income is equal to or above the NSCB
subsistence threshold.
C2 - patients whose aggregate monthly family income is more than 50% of the NSCB
subsistence threshold.
C3 - patients whose aggregate monthly family income is less than 50% but more than
20% of the NSCB subsistence threshold.
d. Class D - Complete social service/Indigent
Patients below class C3. Patients with no visible income or means of support. Patients who
are covered by special laws.
(see also Administrative Order No. 171 s., 2004 dated October 1, 2004 – Policies and Guidelines
to Implement the Relevant Provisions of RA 9257 “Expanded Senior citizens Act of 2003”
DOHwebsite: www.doh.gov.ph)
9
BED OCCUPANCY RATE -
Based on Authorized Bed
Total In-patient service days for a period
(Total no. of authorized beds) x (Total days in the same period)
x 100
AVERAGE NO. OF IN-PATIENT PER DAY- Total in-patient service days for a period
Total days in the same period
AVERAGE LENGTH OF STAY (ALOS) - Total Length of stay of discharged patients (incl. Deaths) for a period
Total discharges and deaths in the period
GROSS DEATH RATE – Total Deaths (including newborn) for a given period
Total Discharges (including deaths) for the same period
NET DEATH RATE -
x 100
[{Total Deaths (incl. Newborn)} – {those under 48 hrs. for the period}]
[{Total No. of Discharges (including deaths and newborn)} - {death under48
hours for the period}]
x 100
CEASAREAN SECTION RATE -Total ceasarean sections in a given period
Total OB Discharges x 100
FETAL DEATH RATE - Death of an offspring to its complete expulsion or extraction from the womb
regardless of duration of pregnancy
Total No. of intermediate and/or late fetal deaths for the period
Total No. of livebirths ( incl. Intermediate and late fetal deaths) for the
period
x 100
Early fetal deaths - < 22 completed weeks of gestation or 500g. birthweight
Late fetal deaths - 22 or more completed weeks of gestation or 500g. or more birthweight
NEONATAL DEATH RATE -
Death of child whose heart beat after complete expulsion of mother
died within 28 days of birth
Total No. of newborn deaths for the period
Total No. of newborn discharges (including deaths) for the same period x100
Early neonatal deaths - < 24 hours of birth
INFANT DEATH RATE -
Measures the risk of dying during the 1st year of life
Total No. of deaths under 1 year of age for the period
x 100
Total No. of infant discharges (including deaths) for the same period
MATERNAL DEATH RATE -
Death of any woman, from any cause while pregnant or within
42 days of termination of pregnancy
Total No. of direct maternal deaths for the period
Total No. of maternal (OB) discharges (including deaths) for the period x100
10
