Annual Patient Care Statistics Report

Annual Patient Care Statistics Report
Please complete this form to report your facility's annual patient care statistics. Accurate reporting helps improve healthcare services and planning.
Facility Name*
Facility Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Reporting Year*
Contact Person Full Name*
First NameLast Name
Contact Email Address*
example@example.com
Total Number of Patients Served*
Patient Demographics Breakdown*
Rows Children (0-17) Adults (18-64) Seniors (65+)
Male
Female
Other/Not Specified
InpatientOutpatientEmergencySurgicalMaternityPediatricRehabilitationOther
Patient Outcomes*
Rows Number of Discharges Number of Deaths Number of Transfers
Inpatient
Outpatient
Emergency
Top 3 Most Common Diagnoses or Conditions Treated*
Staffing Levels (Enter the total number of staff for each category)*
Rows Full-Time Part-Time Contract/Temp
Physicians
Nurses
Allied Health Professionals
Support Staff
Average Length of Stay (In Days) for Inpatients
Additional Comments or Notes
Should be Empty:

Rows	Full-Time	Part-Time	Contract/Temp
Physicians
Nurses
Allied Health Professionals
Support Staff