Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

12/Floor City State Center, 709 show Blvd.brngy.orando Pasig city
MANDATORY MONTHLY HOSPITAL REPORT

For the month of: November 2007

Accreditation No 780329-P Region: IX
Name of Hospital: Redoble medical clinic Category: Primary
Add.no.of Street: Poblacion Buug Zamboanga sibugay PHIC Accredited bed: 8
Municipality: Buug DOH authorized bed: 8
Province: Zamboanga sibugay
Zip code 7009
1. DAILY CENSUS OF NHIP PATIENTS (EVERY 12:00MN) CENSUS FOR THE DAY= (CENSUS OF THE PREVIOUS DAY plus ADMISSION OF THE

DAY minus DISCHARGES OF THE DAY

1 2 1 2
DATE CENSUS DATE CENSUS
a.NHP b.NON-NHP c. TOTAL a.NHP b.NON-NHP c. TOTAL
1 0 4 4 1 0 3 3
2 0 3 3 2 0 4 4
3 0 0 0 3 0 2 2
4 0 6 6 4 0 1 1
5 0 2 2 5 0 3 3
6 0 5 5 6 0 7 7
7 0 3 3 7 0 3 3
8 0 1 1 8 0 3 3
9 0 1 1 9 0 0 0
10 0 0 0 10 0 2 2
11 0 2 2 11 0 0 0
12 0 2 2 12 0 2 2
13 0 0 0 13 0 1 1
14 0 0 0 14 0 0 0
15 0 4 4 15 0 1 1
16 0 5 5 16 0 2 2
17 0 1 1 17 0 6 6
18 0 1 1 18 0 1 1
19 0 3 3 19 0 1 1
20 0 3 3 20 0 6 6
21 0 2 2 21 0 0 0
22 0 0 0 22 0 0 0
23 0 2 2 23 0 2 2
24 0 6 6 24 0 2 2
25 0 2 2 25 0 6 6
26 0 3 3 26 0 2 2
27 0 2 2 27 0 2 2
28 0 2 2 28 0 1 1
29 0 1 1 29 0 3 3
30 0 30 0 1 1
31 0 31 0
TOTAL 0 66 66 TOTAL 0 68 68

B.QUALITY ASSURANCE INDICATOR

1. Monthly bed occupancy Rate (MBOR) =28% 3.Average length of stay per NHIP patient

Total of NHIP CENSUS plus Total of NON-NHIP CENSUS (ALSP) = Zero

MBOR=--------------------------------------------------------------------X 100
Number of days per month indicated multiplied by Number of DOH authorized beds Total of NHIP CENSUS

2. Monthly NHIP Beneficiary occupancy rate (MNHIPBOR) = Zero ALSP =-------------------

Total of NHIP CENSUS Total NHIP DISCHARGES

MNHIPBOR= ---------------------------------------------------------------X 100

C.NEW BORN CENSUS

PARENT
NHIP NON-NHIP TOTAL
TOTAL OF NEW BBORN

DATE RECIEPT: PRO/S _____________________________ RECORDS SECTION_________________ ACCREDITATION______________

Note: This is a mandatory Hospital record to be submitted within the e first 10 days of the following month
D. MOST COMMON CAUSES OF CONFINEMENT
TOTAL
SURGICAL PROCEDURES
NHIP NON-NHIP
1. Acute Gastroenteritis 0 22
2.Pneumonia 0 4
3.URTI 0 3
4.Amoebic Coilitis 0 3
5.Acute Gastritis 0 2
6.CAP 0 2
7.BFS 0 2
8.Enteric Fever 0 2
9.CVA 0 2
10.UTI 0 1

E.SURGICAL OUTPUT
TOTAL
SURGICAL PROCEDURES
NHIP NON-NHIP

E.1TOTAL SURGICAL SREILAZATION

TOTAL
SURGICAL SREILIZATION PROCEDURES
NHIP NON-NHIP
1.BILATERAL TUBAL LIGATION
2.VASECTOMY
TOTAL

F.OBSTETRECAL PROCEDURES
TOTAL
NHIP NON-NHIP
F1.TOTAL NO.OF DELIVERIES(NSD PLUS CAESARIAN SECTION
F2.TOTAL NO.OFCAESARIAN CASES

G.MONTHLY MORALITY CENSUS (ALL CASES)

TOTAL
DIAGNOSIS
NHIP NON-NHIP
1
2
3
4
5

H.REFERRALS

TOTAL
MOST COMMON REASONS FOR REFERRAL NHIP NON-NHIP

PREPARED BY: CERTIFIED CORRECT:

_____________________________________________ ____________________________________________
Name of Position of Person filling up the form Chief of hospital/ Medical director
(Signature over printed name) (Signature over printed name)