Operating Room KPI Report Form
Use this form to report operating room performance metrics, delays, issues, and follow-up actions for the selected reporting period.
Report Context
Report Period
*
Please Select
Month
Date Range
Report Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hospital / Facility Name
*
Department / Unit
*
Operating Room Number / Suite
*
Submitted By (Name)
*
First Name
Middle Name
Last Name
Operational KPI Data
Total Procedures / Cases Completed
*
Elective Cases
*
Emergency / Add-on Cases
*
First Case Performance Type
*
First case start time
On-time first case starts
Average Turnover Time (minutes)
*
Average Case Duration (minutes)
*
Room Utilization (%)
*
Delayed Starts
*
Cancellations
*
Delays, Issues, and Follow-up
Delay reasons
Staffing
Equipment
Patient readiness
Documentation
Bed availability
Surgeon unavailable
Anesthesia delay
Other
Equipment or supply issues reported?
*
Yes
No
Equipment or supply issue description
Incidents or complications affecting workflow?
*
Yes
No
Incident or complication description
Staffing shortage or schedule gap?
*
Yes
No
KPI trend notes, corrective actions, and management comments
Submit Report
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