Free 49933.pdf - Indiana

ASC UTILIZATION REPORT
State Form 49933 (R3/6-05)

INDIANA STATE DEPARTMENT OF HEALTH Acute Care

I. Center Identification Organization Name Street Address City Name of Individual completing report ASC Web Address: Accredited? Yes: __ No: ___ Corporate Tax Status County Email Address of Administrator Date of the end of the Fiscal Year: Name of Accrediting Body For Profit Deemed Status Yes: No:____ Nonprofit

II. Identification of Surgical Resources A. Number of Operating Rooms Class A Class B

Class C

B. Employees (Full Time Equivalents) at end of Fiscal Year Physician (MD/DO) Employees C. Laboratory Services Have On Site Laboratory Yes__ No:___ Have Off-Site contracted laboratory Yes:___ No:_____ Name of Contracted Lab Practitioners (Dentists, etc) RN/LPN Surgical Tech Other Employees

CLIA Certificate Number Type of CLIA Certificate (Check One) Certificate of Certificate of Certificate of Compliance: Accreditation: Waiver:

Certificate for Provider Microscopy Procedures :

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ISDH

ASC UTILIZATION REPORT

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D. Ancillary Services (Check if service available during fiscal year) Radiology On Site by ASC Contractual or by Referral III. Utilization Statistics EKG Pharmacy

A. Total Patients and Procedures
TIME PERIOD Since the Beginning of the Year NUMBER OF PATIENTS NUMBER OF PROCEDURES

B. Ten Most Frequent Surgical Procedures Performed by Demographic Characteristics CPT CODE TOTAL
PROCED.

Number of Procedures based on age and gender characteristics FEMALES 1-17 YEARS 18-64 YEARS AGE 65+ YEARS

All Others Total

C. ASA Risk Classification for Surgical Procedures

Please identify the number of patients by the risk categorization recommended by the American Society of Anesthesiologist. Class 4 combines the ASA P5 and P6 categories. The web site can be found at http://www.asahq.org/clinical/physicalstatus.htm

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ISDH ASC UTILIZATION REPORT # of Patients with no # of Mild Systemic # of Severe medical problems Disease Systemic Disease (Class 1) (Class 2) (Class 3)

Page 3 # of Disease Threatening Life (Class 4)

IV. Outcomes from Surgical Procedures A. Number of Patient Transfers to Inpatient Facilities STABLE TRANSFERS Additional Intervention Therapy Antibiotic Therapy Bleeding EKG Changes Nausea - Vomiting Observation Pain Control IV Therapy Planned Referral and Transfer Total Stable Transfers B. Other Outcomes Number Number of Patients with a Post-Surgical Wound Infection within 30 days following a surgical encounter Number Of Patient Deaths Occurring in the Center Number of patients who stayed in the ASC greater than 24 hours: _____ patients % of Cases NUMBER OF TRANSFERS UNSTABLE TRANSFERS Additional Intervention Therapy Anaphylactic Reaction Angioplasty PTCA Procedure Breathing Difficulties Respiratory Distress CABG CV Surgery Chest Pain EKG Changes Seizures Unstable Medical Condition Total Unstable Transfers NUMBER OF TRANSFERS

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