AGENCY FOR HEALTH CARE ADMINISTRATION

AGENCY FOR HEALTH CARE ADMINISTRATION
Semi-Annual Report of Hospice Utilization (July-December)
Hospice: Service Area(s): ____ Calendar Year: ______
Contact Person: Phone: FAX: Email Address: ______________
| 1. Number of patients admitted to your program | 2. Total patient census |3. For the caseload on July 1: |
|(unduplicated) for the following categories: |(caseload) on these: |Number of patients in: |
| | dates: | |
| | | | | | | |
|Diagnosis |New Patients |TOTALS |Jul 1 | | |Private|
| |Admitted | | | | |Home |
4. Total patient days of care July 1st through December 31st:
| 5. Hospice with a SINGLE | 6. Hospice with TWO or THREE designated service areas: |
|designated service area: | |
| Service Area | Service Area | Service Area | Service Area |
|Number: ________ |Number: ________ |Number: ________ |Number: ________ |
| | | | |
| Total new patients admitted | Total new patients admitted | Total new patients admitted | Total new patients admitted |
|in each month: |In each month: |in each month: |in each month: |
Jul | | |
Jul | | |
Jul | | |
Jul | | | |
Aug | | |
Aug | | |
Aug | | |
Aug | | | |
Sep | | |
Sep | | |
Sep | | |
Sep | | | |
Oct | | |
Oct | | |
Oct | | |
Oct | | | |
Nov | | |
Nov | | |
Nov | | |
Nov | | | |
Dec | | |
Dec | | |
Dec | | |
Dec | | | |
Total | | |
Total | | |
Total | | |
Total | | | |
REVIEWED/APPROVED BY:
(Administrator’s Signature) (Date)
................
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