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  1. 1. Office for Oregon Health Policy Oregon Hospitals and Research 2004 Annual Report March 2005
  2. 2. The Report Purpose of the Report: The submission of this report is required under ORS 442.463. The report provides planners and policy makers’ statewide information on health services, staff and facilities. Information from this report will be available to the public. As such, it is important that reporting be clear, accurate and complete. Do not omit data. Scope of the Project: The 2004 Annual Hospital Report covers only the portion of the facility licensed as a “Hospital”. DO NOT record any nursing home information in this report. Nursing home care information should be reported on the Annual Report for Nursing Homes and Hospital Long-Term Care Units. Reporting Period: Use YOUR FACILITY’S FISCAL YEAR ENDING IN 2004 as your reporting period. Please complete all questions. Remember to read the instructions and explanations on each page. This is an electronic Microsoft Word form. Once you have entered your data on this form, please e-mail to Katya.Medvedeva@state.or.us. If submitting in paper format, please TYPE or PRINT LEGIBLY in INK
  3. 3. DO NOT USE PENCIL PLEASE REMEMBER TO READ ALL DIRECTIONS ENCLOSED! 2004 ANNUAL REPORT FOR OREGON HOSPITALS AND SPECIAL INPATIENT CARE FACILITIES I. GENERAL INFORMATION Facility Information A. Name of Facility       B. CMS ID#       C. Street Address       D. County       E. City       F. Zip Code       G. Facility Web Address (URL)       H. Owner of Facility       I. Administrator Name       J. Administrator Title       K. Administrator Phone Number       L. Administrator Email       Reporter’s Information A. Person Completing Report       B. Title       C. Telephone Number       D. Email Address       E. Street Address      
  4. 4. F. City       G. Zip Code      
  5. 5. Facility________________________________________________________ *******If submitting on paper form, please fill in on every page****** II. Facilities and Services For each of the facilities or services listed below, check how each is provided. 1. The service is provided by the HOSPITAL. 2. The service is provided through a CONTRACTUAL ARRANGEMENT, by a provider not part of hospital staff. If your facility does not provide a service, leave it blank. 1 2 SERVICE 1 2 SERVICE Airborne infection isolation room (AIIR) Neonatal Intensive Care (No. of AIIR rooms___     ________) Neonatal Intermediate Care Alzheimer’s Center Newborn Nursery Alcohol/Chem. Dep. Inpatient Neurological Services Alcohol/Chem. Dep. Outpatient Obstetrics Unit (Level ___     _______) Alcohol/Chem. Dep. Res/Day Occupational Health Services Ambulatory Surgery Services Oncology Services Angiography Services Orthopedic Services Bariatric/Weight Control Services Pain Management Birthing Room/LDR/ LDRP Room Patient Education Center Burn Unit Pediatric Intensive Care Blood Bank Pediatric Medical/Surgical Unit Cardiac Intensive Care Unit Pharmacy Cardiology Services Physical Rehabilitation Inpatient a. Angioplasty Physical Rehabilitation Outpatient b. Cardiac Catheterization Lab. Psychiatric Services c. Open Heart Surgery Psych. Day Or Part. Hospitalization Case Management Psych. Emergency Services Clinical Laboratory Psych. Holding Beds Clinical Psychology Services Psych. Pediatric Services Combined Critical/Intensive Care Psych. Outpatient Services Complementary Medicine Services Psych. Residential Unit Cooperative Care Unit Radiology Services, Diagnostic Coronary Care Unit a. CT Scanner Diagnostic Radioisotope Services b. Diagnostic radioisotope facility Emergency Department c. Electron Beam Computed Tomography (EBCT) End of Life Services d. Magnetic Resonance Imaging (MRI) a. Hospice e. Multislice Spiral Computed Tomography (MSCT) b. Pain Management Program f. Positron Emission Tomography (PET) g. Single Photon Emission Computerized Tom c. Palliative Care Program (SPECT) Extracorporeal shock wave lithotripter h. Digital fluoroscopy (ESWL) General Medical/Surgical Unit i. Ultrasound Page 5 ~ Hospital ~ 2004 Annual Reporting
  6. 6. Facility________________________________________________________ *******If submitting on paper form, please fill in on every page****** II. Facilities and Services (Continued) 1. The service is provided by the HOSPITAL. 2. The service is provided through a CONTRACTUAL ARRANGEMENT, by a provider not part of hospital staff. 1 2 SERVICE 1 2 SERVICE Geriatric Services Radiation Therapy Gamma Knife Recreational Therapy Services Hemodialysis Unit Respiratory Therapy Services Home Health Services Sleep Center Intensive Care Unit Speech Pathology Services Intermediate Care Unit Stroke Center Kidney Dialysis Services Swing Beds Long-Term Care Unit Therapeutic Radioisotope Unit a. Skilled Nursing Transplant Services b. Non-Skilled Nursing Trauma Center (certified) Level ___     ______ Linguistic/Translation Services Trauma Registry Medical/Surgical Intensive Care Tumor Registry Megavoltage Radiation Therapy Urgent Care Center III. Inpatient Services Utilization – Patients Report data ONLY IF YOUR FACILITY HAS A DEDICATED UNIT FOR THE SPECIFIC CARE AREA. Report beds set up, staffed and available for use as of the last day of your facility’s reporting period. DO NOT INCLUDE any long-term care figures except on Line 13. Check what type of patient record you are reporting: Admissions Discharges Number of Total patient licensed beds on Total inpatients days the last day of Inpatient Care Area (For reporting period (For reporting your reporting by care area) period by care period by care area) area 1. Obstetrics                   2. Pediatric medical/surgical                   3. Combined ICU/CCU                   4. Alcohol/Drug                   5. Psychiatric                   6. Psychiatric Holding                   7. Pediatric ICU                   8. Rehabilitation                   9. Other Medical/Surgical                   10. Nursery                   11. Neonatal Special Care Unit                   12. Swing Beds                   13. Special Units                   Specify:      Page 6 ~ Hospital ~ 2004 Annual Reporting
  7. 7. Facility________________________________________________________ *******If submitting on paper form, please fill in on every page****** IV. General Utilization and Staffing General Utilization (FY 2004) The number of patients in the hospital on the last day of your reporting period. Patient Census:       DO NOT INCLUDE NEWBORNS, TRANSFERS, OR LONG- Date:       TERM CARE PATIENTS IN THIS FIGURE. The greatest number of patients in the hospital on a single day during your reporting period. Peak Census:       DO NOT INCLUDE NEWBORNS, TRANSFERS, OR LONG- Count:       TERM CARE PATIENTS. The date (month, day, year) during the reporting period that Peak Census Date:       the peak census count was made. Staffing Physicians Total Number of Physicians Total Number of Physicians (Include with with admitting privileges on residents/fellows) Admitting Privileges the last day of your reporting period. Include all physicians             that are on the facility’s staff. Page 7 ~ Hospital ~ 2004 Annual Reporting
  8. 8. Staffing (Continued) Please indicate the number of personnel on payroll at your facility on the last day of your reporting period. INCLUDE staff providing services for inpatient, outpatient and ancillary services. REPORT both full-time equivalents (FTE) and total personnel. FTE is calculated by dividing the hours an employee works weekly by 40. Number of Category Personnel FTE Admitting Clerks             Certified Nursing Assistants (CNA)             Clinic nurses (Registered)             Clinic receptionist             Departmental Secretary             Dietician             Dietician assistant             Food Services Worker             Housekeepers/Environmental Service Workers             Information Systems, Information Technologists,             Telecommunications (IS/IT) Laboratory Technologist             Licensed Practical Nurses (LPN)             Medical Assistants             Medical Technologist             Nurses (Registered, not clinic nurses)             Occupational Therapist             Occupational Therapist Assistants and Aides             Pharmacist             Pharmacist Technicians and Assistants             Physical Therapist             Physical Therapist Assistant and Aides             Radiologic Technologist, Registered             Respiratory Therapist, Registered             Respiratory Therapist Technician             Social Worker             Speech Therapist             Transcriptionist, Medical             Unit Secretary             Other aides and orderlies             Other, specify:                   TOTAL            
  9. 9. Facility_____________________________________________________ ******If submitting on paper form, please fill in on every page****** V. Utilization of Other Services REPORT FOR FY 2004 DEFINITIONS Operation: A visit by a patient to the surgical suite for major or minor surgery (including endoscopic surgical procedures), regardless of the number of procedures performed. Surgical Procedure: A separate and distinct surgical act, more than one of which may be performed during a operation and performed in a “qualified” operating room (as defined by JCAHO) upon a patient who was not admitted as an inpatient or did not stay in the hospital over 24 hours. Surgical Category: Categories based upon the body system upon which a particular surgical procedure was performed. CPT codes: A systematic listing and coding of procedures and services developed by the American Medical Association. For further definition of a particular surgical procedure, refer to the Current Procedural Terminology, CPT 2003, Professional Edition, American Medical Association. SURGICAL SERVICES Report the number of operations and procedures for inpatients and outpatients, FY2004. Surgery Volume Inpatient Outpatient No. of Operations             No. of Procedures            
  10. 10. Facility_____________________________________________________ ******If submitting on paper form, please fill in on every page****** UTILIZATION OF SURGICAL OUTPATIENT SERVICES Tally the number of specific outpatient surgical procedures and operations in each category listed below. In cases of more then one procedure category: The operation is associated with the PRIMARY procedure category. Include all locations where that outpatient service was provided. Total the procedures and operations performed in each category. Both CPT and ICD-9-CM codes are listed for reference. Exclude births (both mother and newborn) ICD-9-CM Number of Number of Surgical Category/Procedure Equivalent Procedures Operations (Series) Cardiology Surgery (CPT 33010-33999) 35-39             Digestive System Surgery (CPT 43020-44979,             42-47,50-54 45300-45387, 47000-49999) Endocrine System Surgery (CPT             06-07 60000-60699) Gynecological Surgery (CPT 56405-59899) 65-71             Hemic And Lymphatic System Surgery (CPT             40-41 38100-38999) Integumentary Surgery (CPT 10040-19499) 85-86             Neurological Surgery (CPT 61000-64999) 01-05             Ophthalmologic Surgery (CPT 65091-68899) 08-16             Oral Surgery (CPT 40490-42999) 23-24             Orthopedic Surgery (CPT 20000-29999) 76-84             Otolaryngological Surgery (CPT 30000-31599,             18-22,25-31 69000-69990) Proctology Surgery (CPT 45000-45190,             48-49 45500-46999) Thoracic Surgery (CPT 31600-32999,             32-34 39000-39599) Urological Surgery (CPT 50010-55980) 55-64             Vascular Surgery (CPT 34001-37799) 38-39             Other Outpatient Surgery, specify:                         TOTAL       Average OR Time Per Case (In Minutes)       Average Length Of Stay (In       Hours)      
  11. 11. Facility_____________________________________________________ ******If submitting on paper form, please fill in on every page****** OUTPATIENT SURGERY Report the outpatient surgery revenue and the number of operations by each source for the services delivered in your facility during your reporting period. Total charges should equal the gross revenue generated by ambulatory surgery. Number of Primary Source of Payment Charges Operations 1. Medicare             2. Medicaid             3. Title V             4. Other Government Source             5. Workers’ Compensation             6. Blue Cross             7. Other Commercial Insurance Companies             8. Self Pay             9. Other Source of Payment             10. No charge/Uncompensated             TOT             AL THANK YOU FOR YOUR TIMELY RESPONSE ALL 2004 DATA SUBMISSIONS ARE DUE NO LETER THAN MAY 27, 2005 For Microsoft Word Electronic Form, e-mail completed survey to: Katya.Medvedeva@state.or.us For Paper Form, mail to: Katya Medvedeva Office for Oregon Health Policy and Research 255 Capitol Street NE, 5th floor Salem, OR 97310 If you have any questions about this report, please contact: Tina Edlund (503) 378-2422 x400 Tina.Edlund@state.or.us