Hospital Outpatient Volume Report
Please complete this form to report outpatient visit statistics and related data for your hospital or clinic.
Reporting Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporting Department/Unit
*
Please Select
General Medicine
Pediatrics
Surgery
Obstetrics & Gynecology
Orthopedics
Cardiology
Dermatology
ENT
Other
Total Number of Outpatient Visits
*
Breakdown of Visits by Patient Type
*
Rows
New Patient
Follow-up Patient
Emergency Visit
Number of Visits
Age Group Distribution of Outpatients
Rows
0-12 years
13-18 years
19-64 years
65+ years
Male
Female
Other
Average Patient Wait Time (minutes)
Number of Appointment Cancellations
Number of No-Shows
Were there any notable operational issues today?
*
No issues reported
Yes, issues occurred (please specify below)
If yes, please describe the operational issues encountered.
Comments or Additional Notes
Reporting Staff Name
*
First Name
Last Name
Reporting Staff Email Address
*
example@example.com
Submit Report
Should be Empty: