OFFICE OF THE STATE MEDICAL COMMISSIONER

EMPLOYEES' STATE INSURANCE CORPORATION

REGIONAL OFFICE: PANCHDEEP BHAWAN: UNIT-IX: BHUBANESWAR-22
Fax:2546377, Tel:2546684, e-mail: smc-orissa@esic.nic.in

STATUS REPORT FORMAT FOR ESI HOSPITALS

Name of the reporting hospital : ……………………………………………………………………………………………..….

Date of Inspection : ……………………………..
Total bed strength ………………………………. Operational bed strength …………………………………
Number of Ambulances functional in the hospital …………………………………………………………………………………….

1. Information regarding medical attendance of Insured Persons/beneficiaries :-

Sl. Patient Attendance in last Male Female Child <12 Yrs. Total
No. completed month
1. OPD Attendance
2. IPD Attendance
3. Dental Patient Attendance
4. AYUSH Patient Attendance

2. Information pertaining to in house medical services provided in the hospital :-

Sl. Data Items Total in last Sl. Data Items Total in

No. month No. last
month
1. Lab investigation (blood/urine/body 5. Immunization
fluid/others) (No. of doses
2. Radiological BCG
X-Ray DPT
Ultrasound OPV
3. Family Welfare Measles
Deliveries (Total) HBV
LSCS Tetanus
Sterilisation (Male) Anti-rabies Vaccines
Sterilisation (Female) MMR
MTP
IUD Insertions 6. Surgeries
ANC visit Minor O.T
4. ECG Major O.T.
3. Please write yes/no regarding availability of ‘round the clock’ (24X7) medical
services/speciality services under each category, in the hospital :-

Lab services Radiological Services O.T. I.C.U. N.I.C.U. PICU

Medicine Surgery Gyn & Ortho Pediatrics Casualty

Obst.

4. Staff position :

Category Sanctioned Posted Vcant

Doctors (IMO/SR/JR)
Doctors (Specialists)
Doctors (Super Specialist)
Nursing Staff
Other Paramedicals
Administrative staff
Officer & ministerial staff
Total

5. Status of Dhanwantri Project (Progress made till now) :-

a. Percentage OPD registration:
b. Percentage admission-discharge :

6. Information regarding last three Hospital Development Committee meetings

(Provide information as annexure if the space provided in insufficient) :-

Date on which Important Action taken on Achievement of Remarks

HDC held decision taken decision decision taken

7. Mention major equipment available in hospital (specialty wise) :-

a. Gyn. & Obst. :

b. Surgery:
c. Medicine:
d. Pediatrics:
e. Orthopedics:
 f. Ophthalmology :
g. ENT:
h. Radiology:
i. Dental:
j. ICU:
k. Laundary/CSSD/BMW management:
l. Others:

8. Mention major equipment required for the hospital (specialty wise) :

a. Gyn. & Obst. :

b. Surgery:
c. Medicine:
d. Pediatrics:
e. Orthopedics:
f. Ophthalmology :
g. ENT:
h. Radiology:
i. Dental:
j. ICU:
k. Laundary/CSSD/BMW management:
l. Others:

9. Mention any if issues, pending at Headquarter for decision/approval/

instructions, etc. :-

10. Matters pertaining to absorption of State Government Employees, if any :-

11. Any special issue of mention pertaining to hospital functioning :-

Signature of RD Signature of SMC