Hospital Statistical Report

DIVINE PROVIDENCE INFIRMARY & DIAGNOSTIC CENTER
ALS Building, Halsema Highway

Caponga (Poblacion), Tublay, Benguet 2615
665-7489 / +63 920 729 5946
MONTHLY HOSPITAL STATISTICAL REPORT

MONTH - JULY 2019
Name of Hospital: ________________________ Street Address: _____________________________________
Municipality: __________________ Province ______________ Region: ______________________________
Contact No.: __________________________________ Fax Number:__________________________________
Email Address: _____________________________________________________________________________
(PLEASE FILL OUT ALL ITEMS. PUT N/A IF NOT APPLICABLE.)
I. GENERAL INFORMATION
A. Classification
1. Service Capability
 Service capability: Capability of a hospital/other health facility to render administrative, clinical, ancillary and
other services
General: Specialty: (Specify)

[ ] Level 1 Hospital [ ] Treats a particular disease (Specify):_______________
[ ] Level 2 Hospital [ ] Treats a particular organ (Specify):________________
[ ] Level 3 Hospital (Teaching/ Training) [ ] Treats a particular class of patients (Specify):________
[ ] Others (Specify):____________
Trauma Capability: [ ] Trauma Capable [ ] Trauma Receiving
2. Nature of Ownership
Government: Private:
[ ] National –DOH Retained/ Renationalized [ ] Single Proprietorship/Partnership/Corp.
[ ] Local (Specify): [ ] Religious
[ ] Province [ ] Civic Organization
[ ] City [ ] Foundation
[ ] District [ ] Others (Specify):________________
[ ] Municipality
[ ] DND/ DOJ
[ ] State Universities and Colleges (SUCs)
[ ] Others (Specify):_________________
B. Quality Management
 Quality Management/ Quality Assurance Program: Organized set of activities designed to demonstrate on-going
assessment of important aspects of patient care and services
HOS-Stat Report Form
[ ] ISO Certified (Specify ISO Certifying Body and Revision: 03
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area(s) of the hospital with Certification) Validity Period ____________
[ ] International Accreditation Validity Period ____________
[ ] PhilHealth Accreditation Validity Period ____________

[ ] Basic Participation
[ ] Advanced Participation
[ ] PCAHO Validity Period ____________
C. Bed Capacity/Occupancy
1. Authorized Bed Capacity: _____ beds

 Authorized bed: Approved number of beds issued by BHFS, the licensing agency of DOH.
2. Implementing Beds: _____ beds

 Implementing beds: Actual beds used (based on hospital management decision)
3. Bed Occupancy Rate (BOR) Based on Authorized Beds: ______%

(Total Inpatient service days for the period)**
(Total number of Authorized beds) x (Total days in the period) X 100
 Bed Occupancy Rate: The percentage of inpatient beds occupied over a period of time. It is a measure of the
intensity of hospital resources utilized by in-patients.
 Inpatient Service days: Unit of measure denoting the services received by one in-patient in one 24 hour period.
 **Inpatient Service days (Bed days) = [(Inpatients remaining at midnight + Total admissions) – Total
discharges/deaths) + (number of admissions and discharges on the same day)].
II. HOSPITAL OPERATIONS
A. Summary of Patients in the Hospital

For each category listed below, please report the total volume of services or procedures performed.
*Inpatient: A patient who stays in a health facility while under treatment.

*Bed day: Bed used for a continuous 24 hours by an inpatient.
Inpatient Care Number
Total number of inpatients (admissions, including newborns)
Total Discharges (Alive)
Total patients admitted and discharged on the same day
Total number of inpatient bed days (service days) HOS-Stat Report Form
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Total number of inpatients transferred TO THIS FACILITY from another

facility for inpatient care
Total number of inpatients transferred FROM THIS FACILITY to

another facility for inpatient care
Total number of patients remaining in the hospital as of midnight last day of

previous year
B. Discharges
Kindly accomplish the “Type of Service and Total Discharges According to Specialty” in the table below.
Type of Accomodation Condition on Discharge
Type No Total H O R T H A U Total

of of Length Non- Philhealth Philhealth M W / Dis-
Service Pts of Deaths charges
O W I
Stay/ Total A
Total Pay Total < 48 > 48 Total
No. of Service Pay Service hrs hrs
Days Charity
Stay Member/ Indi-
Dependent gent
Medicine
Obstetrics
Gynecology
Pediatrics
Surgery:
Pedia
Adult
Others,
Specify
TOTAL
Total
Newborn
-Pathologic
-Non-Patho
* R/I – Recovered/Improved T- Transferred U - Unimproved

H- Home Against Medical Advice A – Absconded D – Died (died upon admission)
1. Average Length of Stay (ALOS) of Admitted Patients

Total length of stay of discharged patients (including Deaths) in the period = _________________
Total discharges and deaths in the period
 Average length of stay: Average number of days each inpatient stays in the hospital for each episode of care.
2. Ten Leading causes of Morbidity based on final discharge diagnosis

For each category listed below, please report the total number of cases for the top 10 illnesses/injury.
Cause of Morbidity/Illness/Injury Number ICD-10 Code HOS-Stat Report Form

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(Individual)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

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Cause of Age Distribution of Patients JULY 2019 ICD-10

CODE/
Morbidity (Underlying) TABULAR
Under 1–4 5–9 10 -14 15 –19 20 – 24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & Subtotal
1 over Total LIST
Spell out. Do not M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F

abbreviate.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Kindly accomplish the “Ten Leading Causes of Morbidity/Diseases Disaggregated as to Age and Sex” in the table below.

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3. Total Number of Deliveries

For each category of delivery listed below, please report the total number of deliveries.
Deliveries Number ICD-10 Code
Total number of in-facility deliveries
Total number of live-birth vaginal deliveries (normal)
Total number of live-birth C-section deliveries (Caesarians)
Total number of other deliveries
4. Outpatient Visits, including Emergency Care, Testing and Other Services

For each category of visit of service listed below, please report the total number of patients receiving
the care.
Outpatient visits Number
Number of outpatient visits, new patient
Number of outpatient visits, re-visit
Number of outpatient visits, adult
Number of outpatient visits, pediatric
Number of adult general medicine outpatient visits
Number of specialty (non-surgical) outpatient visits
Number of surgical outpatient visits
Number of antenatal care visits
Number of postnatal care visits

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Emergency visits Number 12/08/2014
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Total number of emergency department visits
Total number of emergency department visits, adult
Total number of emergency department visits, pediatric
Total number of patients transported FROM THIS FACILITY’S

EMERGENCY DEPARTMENT to another facility for inpatient care
Testing Number
Total number of medical imaging tests (all types including x-rays, ultrasound,
CT scans, etc.)
Total number of laboratory and diagnostic tests (all types, excluding medical
imaging)
Other services and diseases seen Number
Total number of outreach or home visits
Total number of immunization doses administered to children 0-59 months at

this facility or during outreach or home visits. Include immunizations
administered during child health weeks.
Total number of newly diagnosed cases of TB
Total number of confirmed cases of dengue
C. Deaths
For each category of death listed below, please report the total number of deaths.
Types of deaths Number
Total deaths
Total number of inpatient deaths
 Total deaths < 48 hours
 Total deaths > 48 hours

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Total number of emergency room deaths
Total number of cases declared ‘dead on arrival’
Total number of stillbirths
Total number of neonatal deaths
Total number of maternal deaths
1. Gross Death Rate ____________%

Gross Death Rate = Total Deaths (including newborn for a given period)
Total Discharges and Deaths for the same period x 100
2. Net Death Rate ____________%

Net Death Rate = Total Death (including newborn for a given period) – death <48 hours for the period
Total Discharges (including deaths and newborn) – death<48 hours for the period x 100
3. Ten Leading Causes of Mortality/Deaths and Total Number of Mortality/Deaths.
Mortality/Deaths Number ICD-10 Code

(Individual)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

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Kindly accomplish the “Ten Leading Causes of Mortality/Deaths Disaggregated as to Age and Sex” in the table below.
Cause of ICD-10
Age Distribution of Patients CODE/
Death (Underlying) Total TABULAR
Under 1–4 5–9 10 -14 15 –19 20 – 24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & Subtotal
1 over LIST
Spell out. Do not M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F

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

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D. Healthcare Associated Infections (HAI)

HAI are infections that patients acquire as a result of healthcare interventions. For purposes of Licensing, the four (4)
major HAI would suffice.
For All Hospitals (Levels 1, 2, 3 General and Specialty)

INFECTION RATE = Number of Healthcare Associated Infections x 100
Number of Discharges
a. Device Related Infections
1. Ventilator Acquired Pneumonia (VAP) = Number of Patients with VAP x 1000

Total Number of Ventilator Days
2. Blood Stream Infection (BSI) = Number of Patients with BSI x 1000

Total Number of Central Line
3. Urinary Tract Infection (UTI) = Number of Patients with UTI x 1000

Total Number of Catheter Days
b. Non-Device Related Infections

Surgical Site Infections (SSI) = Number of Surgical Site Infections x 100
Total number of Procedures
E. Surgical Operations
1. Major Operation refers to surgical procedures requiring anesthesia/ spinal anesthesia to be performed in an operating
theatre. (The definition of a major operation shall be based on the definitions of the different cutting specialties.)
2. Minor Operation refers to surgical procedures requiring only local anesthesia/ no OR needed, example suturing.
10 Leading Major Operations (excluding Caesarian Number ICD-10 Code

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

10 Leading Minor Operations Number ICD-10 Code Revision: 03
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
III. STAFFING PATTERN (Total Staff Complement)
Total staff working full time Total staff working part time Active Out-
Profession/ Position/ (at least 40 hours/week) (at least 20 hours/week) Rotating or sourced
Designation Visiting/
Affiliate
(For Private
Facilities)
Number Number of Number Number of Number of Number
of contractual of permanent contractual of
permanent staff volunteer staff staff volunteer
staff staff staff
A. Medical
1. Consultants
(indicate One-Peso
consultant)
1.1. Internal Medicine
a. Generalist
b. Cardiologist
c. Endocrinologist
d. Gastro-
Enterologist
e. Pulmonologist
f. Nephrologist
g. Neurologist
h. Others (Specify)
1.2. Obstetrics/
Gynecology (and
subspecialty)
1.3. Pediatrics (and
subspecialty)
1.4. Surgery (and
subspecialty)
1.5. Anesthesiologist
1.6. Radiologist
1.7. Pathologist Revision: 03
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2. Post-Graduate
Fellows
(Indicate specialty/
subspecialty)
3. Residents
3.1. Internal Medicine
3.2. Obstetricts-
Gynecology
3.3. Pediatrics
3.4. Surgery
3.5. Others (Specify)
B. Allied Medical
1. Nurses
2. Midwives
3. Nursing Aides
4. Nutritionist
5. Physical Therapist
6. Pharmacists
7. Medical
Technologist
8. Others (Specify)
C. Non-Medical
1. Social Workers
2. Medical Records
Officer/ Hospital
Health
Information
Officer with
formal training in
medical records
management
3. Laboratory
Technicians
4. X-Ray Technicians
5. Administrative
Officer
6. Accounting/
Finance Officer
7. General Support
Staff
(maintenance, HOS-Stat Report Form
janitorial, Revision: 03
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secretarial) –
indicate if
outsourced
IV. EXPENSES
Report all money spent by the facility on each category.
Expenses Amount in
Pesos
Amount spent on personnel salaries and wages
Amount spent on benefits for employees (benefits are in addition to wages/salaries.

Benefits include for example: social security contributions, health insurance)
Allowances provided to employees at this facility (Allowances are in addition to

wages/salaries. Allowances include for example: clothing allowance, PERA, vehicle
maintenance allowance and hazard pay.)
TOTAL amount spent on all personnel including wages, salaries, benefits and
allowances for last year (PS)
Total amount spent on medicines funded by the Revolving Fund
Total amount spent on medicines funded by the Government of the Philippines (from
any level of government, including the central, provincial and municipal
governments)
Total amount spent on medical supplies (i.e. syringe, gauze, etc.; exclude
pharmaceuticals)
Total amount spent on utilities
Total amount spent on non-medical services (For example: security, food service,
laundry, waste management)
TOTAL amount spent on maintenance and other operating expenditures

(MOOE)
Amount spent on infrastructure (i.e., new hospital wing, installation of ramps)
Amount spent on equipment (i.e. x-ray machine, CT scan)
TOTAL amount spent on capital outlay (CO)
V. REVENUES
Please report the total revenue this facility collected last year. This includes all monetary resources
acquired by this facility from all sources, and for all purposes.
Revenues Amount HOS-Stat

in Report Form
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Pesos
Total amount of money received from the Department of Health
Total amount of money received from the local government
Total amount of money received from donor agencies (for example JICA, USAID,
and others)
Total amount of money received from private organizations (donations from

businesses, NGOs, etc.)
Total amount of money received from Phil Health
Total amount of money received from direct patient/out-of-pocket charges/fees
Total amount of money received from reimbursement from private insurance/HMOs
Total amount of money received from other sources (PDAF, PCSO, etc.)
TOTAL Revenue
Report Prepared by : ____________________________

Designation/Section/Department : ____________________________ Date: _______
Report Approved and Certified by : ____________________________ Date: _______

Chief of Hospital/Medical Director
__________________________________________________________________________________________________________
PREPARED BY:
STANDARDS DEVELOPMENT DIVISION (SDD)

BUREAU OF HEALTH FACILITIES AND SERVICES (BHFS)
DEPARTMENT OF HEALTH (DOH)
APPROVED BY:
ATTY. NICOLAS B. LUTERO III, CESO III

ASSISTANT SECRETARY
DOH

Revision: 03
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DIVINE PROVIDENCE INFIRMARY & DIAGNOSTIC CENTER

ALS Building, Halsema Highway

MONTHLY HOSPITAL STATISTICAL REPORT

Name of Hospital: ________________________ Street Address: _____________________________________

Municipality: __________________ Province ______________ Region: ______________________________

Contact No.: __________________________________ Fax Number:__________________________________

Email Address: _____________________________________________________________________________

(PLEASE FILL OUT ALL ITEMS. PUT N/A IF NOT APPLICABLE.)

General: Specialty: (Specify)

Trauma Capability: [ ] Trauma Capable [ ] Trauma Receiving

area(s) of the hospital with Certification) Validity Period ____________

[ ] International Accreditation Validity Period ____________

[ ] PhilHealth Accreditation Validity Period ____________

[ ] PCAHO Validity Period ____________

1. Authorized Bed Capacity: _____ beds

2. Implementing Beds: _____ beds

3. Bed Occupancy Rate (BOR) Based on Authorized Beds: ______%

II. HOSPITAL OPERATIONS

A. Summary of Patients in the Hospital

*Inpatient: A patient who stays in a health facility while under treatment.

Inpatient Care Number

Total number of inpatients (admissions, including newborns)

Total Discharges (Alive)

Total patients admitted and discharged on the same day

Total number of inpatients transferred TO THIS FACILITY from another

Total number of inpatients transferred FROM THIS FACILITY to

Total number of patients remaining in the hospital as of midnight last day of

Type No Total H O R T H A U Total

* R/I – Recovered/Improved T- Transferred U - Unimproved

1. Average Length of Stay (ALOS) of Admitted Patients

2. Ten Leading causes of Morbidity based on final discharge diagnosis

Cause of Morbidity/Illness/Injury Number ICD-10 Code HOS-Stat Report Form

HOS-Stat Report Form

Cause of Age Distribution of Patients JULY 2019 ICD-10

Spell out. Do not M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F

HOS-Stat Report Form

3. Total Number of Deliveries

Deliveries Number ICD-10 Code

Total number of in-facility deliveries

Total number of live-birth vaginal deliveries (normal)

Total number of live-birth C-section deliveries (Caesarians)

Total number of other deliveries

4. Outpatient Visits, including Emergency Care, Testing and Other Services

Outpatient visits Number

Number of outpatient visits, new patient

Number of outpatient visits, re-visit

Number of outpatient visits, adult

Number of outpatient visits, pediatric

Number of adult general medicine outpatient visits

Number of specialty (non-surgical) outpatient visits

Number of surgical outpatient visits

Number of antenatal care visits

Number of postnatal care visits

HOS-Stat Report Form

Total number of emergency department visits

Total number of emergency department visits, adult

Total number of emergency department visits, pediatric

Total number of patients transported FROM THIS FACILITY’S

Name of Hospital: Street Address: _____________

Municipality: Province Region: ______________

Contact No.: Fax Number:

Report Approved and Certified by : ______________________ Date: _