Fiscal Year | 20...../20..... | T0 | HF Code |
Reference No: | Subject: Submission of Monthly Report on Hospital Services : | M...../Y 20..... |
Hospital Services | Emergency Services | ||||||
Age Group | New Client Serviced | Total Clients Served | Total Clients Served | ||||
Female | Male | Female | Male | Female | Male | ||
{{o.AgeRange}} | {{o.FemaleNew_Out}} | {{o.MaleNew_Out}} | {{o.FemaleTotal_Out}} | {{o.MaleTotal_Out}} | {{o.Female_ER}} | {{o.Male_ER}} |
Free Service Received by Impoverished Citizen |
Female | Male |
1 | 2 | 3 |
{{f.ReportingItemName}} | {{f.FemaleCount}} | {{f.MaleCount}} |
ORC Clinics / FCHV | Planned / Total No. | Conducted / Report Received. | No of Clients Served. |
Outreach Clinic | - | - | - |
Immunization Clinic | - | - | - |
Immunization Session | - | - | {{immunizationServices[0]?.TotalVaccinationClientServed}} |
Hygiene Promotion Session | - | - | - |
FCHV | - | - | - |
Referrals | Referral In | Referred Out | ||
Outpatient | Inpatient | Emergency | ||
Female | - | {{outpatientReferredOut.OpReferred_FemaleCount}} | {{HospitalServiceSummaryReport?.InpatientReferredOut[0]?.IpRO_FemaleCount}} | - |
Male | - | {{outpatientReferredOut.OpReferred_MaleCount}} | {{HospitalServiceSummaryReport?.InpatientReferredOut[0]?.IpRO_MaleCount}} | - |
Available Services (Circle the appropriate code) | Services | Available Services (Circle the appropriate code) | Services | ||
Yes | No | Yes | No | ||
Birthing Center | 1 | 2 | DOTS Site | 1 | 2 |
BEONC Site | 1 | 2 | Microscopy Site | 1 | 2 |
CEONC Site | 1 | 2 | Laboratory Service | 1 | 2 |
Safe Aboration Service (SAS) Site | 1 | 2 | HTC Site | 1 | 2 |
IUCD Service Site | 1 | 2 | PMTCT Site | 1 | 2 |
Implant Service Site | 1 | 2 | CB-PMTCT Site | 1 | 2 |
Adolescent Friendly Service Site | 1 | 2 | ART Site | 1 | 2 |
OTC Site | 1 | 2 | Other (Specify)... | 1 | 2 |
Dispatched Date : | / / 207... | |||||||
Received Date : | / / 207... | |||||||
Sanctioned Bed | Operational Inpatient Bed | Emergency Bed | ||||||
Total Patients Admitted | {{totalPatientAdmitted != null && totalPatientAdmitted.length>0 && !!totalPatientAdmitted[0].TotalPatientsAdmitted ? totalPatientAdmitted[0].TotalPatientsAdmitted : 0}} | |
Total Inpatient Service Days | {{totalInpatientDays != null && totalInpatientDays.length>0 && !!totalInpatientDays[0].TotalInpatientDays ? totalInpatientDays[0].TotalInpatientDays : 0}} |
Diagnostic / Other Services | Unit | No. |
---|---|---|
{{d.ReportingItemName}} | {{d.Unit}} | {{d.TotalCount}} |
Total Laboratory Service Provided | Person | {{TotlLabServiceProvidedPersonCount}} |
Other Service Provided (If any) | Person | - |
Minimun Service Standard (MSS) | Date | Implementation | Score (%) | |
1. First | 2. Second |
Signature:
Name of Medical Recorder:
Signature:
Name of Hospital Superintendent/Director: