Hospital Based Study .edu
Services Use Questionnaire
Preliminary In-patient Care Cost
The first interview will be carried out shortly after hospitalization of the patient
| |Date of interview: | | |
|From Medical Records |
|Q |Date of Admission: | | |
| |Date of Discharge: | | |
|From Patient/Family Interview |
|Q |Where you provided care/services before getting to the hospital? |Yes No | |
| |If Yes, by whom: | | |
| |Parent(s) | | |
| |Siblings | | |
| |Guardian | | |
| |Community Nurse: What was paid? Cost? | | |
| |Traditional healer: What was paid? Cost? | | |
| |Local drug peddlers: What was paid? Cost? | | |
| |Private hospital/clinic: What was paid for? Cost? | | |
| |Others | | |
|Q |How did you get to the hospital? | | |
| |Walking / Family Bicycle / Family motorcycle / Family car | | |
| |Bike taxi / Car taxi / Bus: How much was paid? | | |
| |Animal cart/wagon | | |
| |Ambulance: Did it belong to the government or private hospital? | | |
| |If private hospital, what was paid? | | |
| |Where you accompanied by family relative? |Yes No | |
| |If Yes, Which one? | | |
|Q |Distance from place of abode to hospital: | | |
| |Transportation time: | | |
|Q |Was any fee paid on arrival at the hospital? |Yes No | |
| |If Yes, what was paid? | | |
|Q |What would relatives (specify) have been doing if child/patient was not | | |
| |sick? | | |
|From Medical Records |
|Q |Cost of hospital medical bed per day | | |
|Q |Quantity of Coartem tablets prescribed to patient | | |
| |Quantity of Quinine prescribed to patient | | |
|Q |Any major medical procedures performed on patient while on admission? |Yes No | |
| |If Yes, which one? What was paid? | | |
Incentive will be offered to respondents to return to the hospital after one week for the second interview. All the questions above will be repeated, however, the question “Were you provided care/services before getting to the hospital?” will now become : Were you provided care/services after discharge from the hospital?
If the patient is re-admitted for treatment failure or persistence of symptoms during the specified period, then the interviews are repeated
Preliminary Out-patient Care Cost
| |Date of Interview: | | |
|From Patient/Family Interview |
| |How many visits made to the out-patient clinic for this episode of malaria?| | |
|Q |Where you provided care/services before getting to the clinic? |Yes No | |
| |If Yes, by whom: | | |
| |Parent(s) | | |
| |Siblings | | |
| |Guardian | | |
| |Community Nurse: What was paid? Cost? | | |
| |Traditional healer: What was paid? Cost? | | |
| |Local drug peddlers: What was paid? Cost? | | |
| |Private hospital/clinic: What was paid for? Cost? | | |
| |Others | | |
| | | | |
|Q |How did you get to the hospital? | | |
| |Walking / Family Bicycle / Family motorcycle / Family car | | |
| |Bike taxi / Car taxi / Bus: How much was paid? | | |
| |Animal cart/wagon | | |
| |Ambulance: Did it belong to the government or private hospital? | | |
| |If private hospital, what was paid? | | |
| |Where you accompanied by family relative? | | |
| |If Yes, Which one? | | |
|Q |Distance from place of abode to hospital: | | |
| |Transportation time: | | |
|Q |Was any fee paid on arrival at the hospital? |Yes No | |
| |If Yes, what was paid? | | |
|Q |What would relatives (specify) have been doing if child/patient was not | | |
| |sick? | | |
|From Medical Records |
|Q |How many visits made to the clinic for present episode of malaria? | | |
|Q |Quantity of Coartem tablets prescribed to patient | | |
| |Quantity of Quinine prescribed to patient | | |
|Q |Was patient referred to another hospital for admission? |Yes No | |
| |If Yes, Where? | | |
| |Was patient provided ambulance services? |Yes No | |
| |At what cost? | | |
Incentive will be offered to respondents to show up at the clinic after 1 week for the second interview. All the questions above will be repeated, however, the question “Was the patient (or were you) provided care/services before getting to the hospital?” will now become: Was the patient (or were you) provided care/services after leaving the clinic?
If the patient returns to the clinic treatment failure or persistence of symptoms during the specified period, then the interviews are repeated
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