Adult ICU

S/N Measure -/-/ -/-/ -/-/2015 -/-/2015 -/-/2015 -/-/ -/-/

2015 2015 2015 2015

1 New
admission
2 on MV
3 Death
4 Round Am
5 Round Pm

Trauma ICU

S/N Measure -/-/ -/-/ -/-/2015 -/-/2015 -/-/2015 -/-/ -/-/

2015 2015 2015 2015

1 New
admission
2 on MV
3 Death
4 Round Am
5 Round Pm

Date

Reported by

 Name:

Signature:

NICU

S/N Measure -/-/ -/-/ -/-/2015 -/-/2015 -/-/ -/-/2015 -/-/

2015 2015 2015 2015

1 New
admission
2 Total
admission
3 on CPAP
4 Death
5 Round Am
6 Round Pm

Date

Reported by

Name:

Signature:

 Pediatric ward

S/N Measure -/-/ -/-/ -/-/ -/-/2015 -/-/ -/-/ -/-/2015

2015 2015 2015 2015 2015

1 Total
admission
2 Discharge
3 Death
4 Round Am
5 Round Pm

Date

Reported by

Name:

Signature:

 Medical ward (A)

S/N Measure -/-/2015 -/-/ -/-/ -/-/ -/-/ -/-/2015 -/-/2015

2015 2015 2015 2015

1 Total
admission
2 Discharge
2 Death
3 Round Am
4 Round Pm

Medical ward (B)

S/N Measure -/-/2015 -/-/ -/-/ -/-/ -/-/ -/-/2015 -/-/2015

2015 2015 2015 2015

1 Total
admission

 2 Discharge
2 Death
3 Round Am
4 Round Pm

Date

Reported by

Name:

Signature:

Surgery ward

S/N Measure -/-/ -/-/2015 -/-/ -/-/2015 -/-/2015 -/-/ -/-/

2015 2015 2015 2015

1 Surgery total
2 Total
admission
3 Total
discharge
4 Death
5 Round Am
6 Round Pm

 Date

Reported by

Name:

Signature:

Gyne ward

S/N Measure -/-/ -/-/ -/-/ -/-/2015 -/-/ -/-/ -/-/2015

2015 2015 2015 2015 2015

1 New
admission
2 Total
admission
3 Total
discharge
4 Death
5 Round Am
6 Round Pm

 Date

Reported by

Name:

Signature:

Liaison o ce weekly Report

S/N Measure Remark

1 Referral In Emergenc
y
Cold case
2 Referral out Emergenc
y
Cold case

ffi

 4 Total
admission
5 Total
Discharge

Date

Reported by

Name:

Signature:

Cervical cancer Screening Report

S/N Measure Weekly

1 CA screening

2 Cryo therapy
done

 3 LEEP done

Date

Reported by

Name:

Signature:

OR

S/ Measure -/-/ -/-/ -/-/2015 -/-/2015 -/-/2015 -/-/2015 -/-/2015

N 2015 2015

 E L E L E L E L E L E L E L
1 General
surgery
2 Orthopedic
3 ENT
4 Neuro
surgery
5 Gyn-OBS
6 Pediatric
surgery
7 Urosurgery
8 C/S

Date

Reported by

Name:

Signature:

 Pathology

S/N Measure Previous This week Remark

Result
1 Biopsy
2 FNA
3 Pap smear
4 Peripheral
morphology
5 Cytology
6 Autopsy
Sample
collected
1 Biopsy
2 FNA
3 Pap smear
4 Peripheral
morphology
5 Cytology
6 Autopsy

Date

Reported by

Name:

 Signature:

Radiology & Imaging

S/N Measure

1 X-ray
2 U/S
3 CT scan
4 X-ray Reading
5 U/S Reading
6 CT scan Reading
7 Doppler U/S
8 ECHO

Date

Reported by

Name:

Signature:

 OPD case Team Performance monitoring tool

OPD case team number/Name

Dat Number of pa ent Numbe Number Remark

e OPD seen r of Name of
start case A ending Referral
me Not physician/
A P Repeat seen Health IN OU
M M New the professional/ T
same
AM P A PM day
M M
ti
tt

ti