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Oregon Hospitals2004 Annual Report

March 2005

Office for Oregon Health Policy and Research

Facility________________________________________________________*******If submitting on paper form, please fill in on every page******

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 oneach page.

This is an electronic Microsoft Word form. Once you have entered your data on this

~ Hospital ~ 2004 Annual Reporting


form, please e-mail to [email protected].

If submitting in paper format, please TYPE or PRINT LEGIBLY in INK

DO NOT USE PENCILPLEASE REMEMBER TO READ ALL DIRECTIONS ENCLOSED!

2004 ANNUAL REPORT FOR OREGON HOSPITALS AND SPECIAL INPATIENT CARE FACILITIES

I. GENERAL INFORMATION

Facility InformationA. 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 InformationA. Person Completing Report

B. Title

C. Telephone Number

D. Email Address

E. Street Address


mailto:[email protected]


F. City

G. Zip Code



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.1 2 SERVICE 1 2 SERVICE

Airborne infection isolation room (AIIR)(No. of AIIR rooms___ ________)

Neonatal Intensive Care

Neonatal Intermediate Care

Alzheimer’s Center Newborn NurseryAlcohol/Chem. Dep. Inpatient Neurological ServicesAlcohol/Chem. Dep. Outpatient Obstetrics Unit (Level ___ _______)Alcohol/Chem. Dep. Res/Day Occupational Health Services

Ambulatory Surgery Services Oncology ServicesAngiography Services Orthopedic ServicesBariatric/Weight Control Services Pain Management

Birthing Room/LDR/ LDRP Room Patient Education CenterBurn Unit Pediatric Intensive CareBlood Bank Pediatric Medical/Surgical UnitCardiac Intensive Care Unit Pharmacy

Cardiology Services Physical Rehabilitation Inpatienta. Angioplasty Physical Rehabilitation Outpatient

b. Cardiac Catheterization Lab. Psychiatric Servicesc. Open Heart Surgery Psych. Day Or Part. Hospitalization

Case Management Psych. Emergency ServicesClinical Laboratory Psych. Holding BedsClinical Psychology Services Psych. Pediatric ServicesCombined Critical/Intensive Care Psych. Outpatient ServicesComplementary Medicine Services Psych. Residential Unit

Cooperative Care Unit Radiology Services, DiagnosticCoronary Care Unit a. CT ScannerDiagnostic 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)

c. Palliative Care Program g. Single Photon Emission Computerized Tom (SPECT)

Extracorporeal shock wave lithotripter (ESWL)

h. Digital fluoroscopy

General Medical/Surgical Unit i. Ultrasound

If your facility does not provide a service, leave it blank.



II. Facilities and Services (Continued)1. The service is provided by the HOSPITAL.

1 2 SERVICE 1 2 SERVICEGeriatric Services Radiation TherapyGamma Knife Recreational Therapy ServicesHemodialysis Unit Respiratory Therapy ServicesHome Health Services Sleep Center

Intensive Care Unit Speech Pathology ServicesIntermediate Care Unit Stroke CenterKidney Dialysis Services Swing Beds

Long-Term Care Unit Therapeutic Radioisotope Unita. Skilled Nursing Transplant Services

b. Non-Skilled Nursing Trauma Center (certified) Level ___ ______

Linguistic/Translation Services Trauma RegistryMedical/Surgical Intensive Care Tumor RegistryMegavoltage Radiation Therapy Urgent Care Center

2. The service is provided through a CONTRACTUAL ARRANGEMENT, by a provider not part of hospital staff.

III. Inpatient Services Utilization – PatientsReport 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

Inpatient Care AreaTotal inpatients (For reporting

period by care area)

Total patient days

(For reporting period by care

area)

Number of licensed beds

on the last day of your

reporting period by care

area1. 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 UnitsSpecify:



IV. General Utilization and Staffing

General Utilization (FY 2004)

The number of patients in the hospital on the last day of your reporting period.

DO NOT INCLUDE NEWBORNS, TRANSFERS, OR LONG-TERM CARE PATIENTS IN THIS FIGURE.

Patient Census:

Date:

The greatest number of patients in the hospital on a single day during your reporting period.

DO NOT INCLUDE NEWBORNS, TRANSFERS, OR LONG-TERM CARE PATIENTS.

Peak Census:

Count:

The date (month, day, year) during the reporting period that the peak census count was made.

Peak Census Date:

Staffing

Total Number of Physicians with admitting privileges on the last day of your reporting period. Include all physicians that are on the facility’s staff.

Physicians(Include

residents/fellows)

Total Number of Physicians with

Admitting Privileges


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.

CategoryNumber of 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: TOT

AL

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.

SurgicalProcedure: 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.

SurgicalCategory: 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 SERVICESReport the number of operations and procedures for inpatients and outpatients,

FY2004.

Surgery Volume Inpatient Outpatient

No. of Operations

No. of Procedures


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)

Surgical Category/ProcedureICD-9-CM

Equivalent (Series)

Number of Procedures

Number of Operations

Cardiology Surgery (CPT 33010-33999) 35-39

Digestive System Surgery (CPT 43020-44979, 45300-45387, 47000-49999)

42-47,50-54

Endocrine System Surgery (CPT 60000-60699)

06-07

Gynecological Surgery (CPT 56405-59899)

65-71

Hemic And Lymphatic System Surgery (CPT 38100-38999)

40-41

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, 69000-69990)

18-22,25-31

Proctology Surgery (CPT 45000-45190, 45500-46999)

48-49

Thoracic Surgery (CPT 31600-32999, 39000-39599)

32-34

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)


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.

Primary Source of Payment ChargesNumber of 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

TOTAL

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:

[email protected]

For Paper Form, mail to:Katya MedvedevaOffice for Oregon Health Policy and Research255 Capitol Street NE, 5th floorSalem, OR 97310If you have any questions about this report, please contact:Tina Edlund(503) 378-2422 [email protected]

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Documents

american medical association

term care patients

surgical procedure

medvedeva state

contractual arrangement

admitting privileges

clinic nurses

paper form