Patient Count Ranking Report Form
Submit and rank patient counts by category, period, and location for reporting and analysis.
Reporting Period
*
Please Select
Q1
Q2
Q3
Q4
Year to Date
Custom Range
Custom Date Range (if selected above)
Location
*
Department / Unit
*
Patient Category
*
Please Select
Inpatient
Outpatient
Emergency
Surgical
Other
Patient Count
*
Rank for This Category
*
Please Select
1 (Highest)
2
3
4
5 (Lowest)
Compared To Previous Period
*
Increased
Decreased
No Change
Prepared By (Name)
*
First Name
Last Name
Report Submission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments
Submit Report
Should be Empty: