Académique Documents
Professionnel Documents
Culture Documents
Type of Service
Medicine
Obstetrics
Gybecology
Pediatrics
Surgery
Pedia
Adult
Othes,Specify
Total
Total Newborn
Pathologic
Non-Patho
No. of Pts
Non-Philhealth
Total Length
of Stay
/Total no. of
days stay
P
a
y
Service
Charity
Philhealth
Total
P
a
y
Type Of Accommodation
Condition on Dis
Philhealth
Total
Service
Member/Dependent
Indigent
H
M
O
O
W
W
A
R
/
I
Condition on Discharge
Deaths
Total
Discharge
<48
48
Total
Cause of Morbidity(underlying)
under 1
Spell out . Do not abbreviate
1 to 4
F
5 to 9
F
5 to 9
10 to 14
F
15 - 19
F
20-24
F
25-29
F
25-29
F
40-44
F
45-49
F
45-49
50-54
F
55-59
F
60-64
F
65-69
F
subTotal
65-69
Total
70 & over
F
Cause of Death(underlying)
under 1
Spell out . Do not abbreviate
1 to 4
F
5 to 9
F
5 to 9
10 to 14
F
15 - 19
F
20-24
F
25-29
F
25-29
F
40-44
F
45-49
F
45-49
50-54
F
55-59
F
60-64
F
65-69
F
subTotal
65-69
Total
70 & over
F
ICD-10
Code/Tabu
lar List
Proffesion/Position/Designati
on
Number of
Permanent Staff
A. Medical
1. Consultants ( indicate one peso
consultant
1.1 Internal Medicine
a. Generalist
b. Cardiologist
c. Endocrinologist
d. Gastro-Enterologist
e. Pumonologist
f. Nephro;ogist
g. Neurologist
h. Others(Specify)
1.2 Obstetrics/Gynecology (and
Subspecialty
1.3 Pediatrics (and subspecialty)
1.4 Surgery
1.5 Anesthesiologist
1.6 Radiologist
1.7 Pathologist
2. Post-Graduate Fellows
(indicate Specialty/subspecialty)
3. Resident
3.1 Internal Medicine
3.2 Obstetrics/Gynecology
3.3 Pediatric
3.4 Surgery
3.5 Others (Specify)
b. Allied Medicine
!. Nurses
2. Midwives
3. Nursing Aides
4. Nutritionist
5. Physical Therapists
Number of
Contractual Staff
Number of
Volunteer Staff
6. Pharmacists
7. Medical Technologist
8. Others (specify)
C. Non-Medical
1. Social Worker
2 Medical Records Officer/Hospital
Health Information Officer with
training in medical records
management
3.
4.
5.
6.
Laboratory Technicians
X-ray Techniciana
Administrative Officer
Accounting/Finance Officer
7. General Services Staff
( Maintenance, Janitorial,
secretarial) indicate if outsourced
40 houra/week
Number of
Volunteer Staff
Number of
Permanent Staff
Number of
Contractual Staff
Number of
Volunteer Staff
Active Rotating or
Visiting/Affiliate
(For Private
Facilities
Active Rotating or
Visiting/Affiliate
(For Private
Facilities
Outsourced