MONTHLY REPORT OF CCU / HDU

Annexure I

[This format should be available in all CCU & HDU and send report to Swasthya Bhavan every month]
Reporting Month:
Name of
1 the
District

Purulia

Name Deben
o Mahato (Sadar) Hospital
3 Name Bankura
Sammilani Medical College & Hospital
o
4 Name Dr.Nilanjana
Sen
o
5 Name Dr.P.K
o Mukherjee
6 Date o
41829
7 No. of
12
8 No. of
10
9 No. of
4
10 No. of
4
11 Type oThis Month
M = Ma
M
F
C
ANM PNM Total
2

This details to be given in Annexure III, not to be given here

Report Regarding Patient Admission
No. of
12 patients This Month
admitted
M = Male,

ANM PNM Total

0

Report
regarding
Patient
intake
(Already
under T/t
in outside
hospitals)

13

13.1

No. of
patients
Referred
in from
other
Governme
nt
Institutes

No. of
patients
Referred
in from
other
Private
Institutes

13.2
13.3 TOTAL

Report
regarding
Patient
intake
(Already
under T/t
in same
hospital /
New
patient)

14
14.1 Patient directly admitted from Emergency / OPD
14.2 No. of patients transferred in from other Dept. of the same Institu
14.3 TOTAL
0
0
0
0
0
Report Regarding Procedure done on Patients

0
0
0

15

Repor
t
regar
ding
Invasi
ve
Mech
anical
Ventil
ation

15.1

No. of
Patient
put on
Invasive
Mechanic
al
Ventilatio
n (within
24 hrs of
admission
)

15.2

No. of
Patient
put on
Invasive
Mechanic
al
Ventilatio
n (after
24 hrs of
admission
)

15.3

Mean
duration
of
Invasive
Mechanic
al
Ventilatio
n

15.4 TOTAL

16

Repor
t
regar
ding
Non
Invasi
ve
Mech
anical
Ventil
ation

16.1

No. of
Patient
put on
Non
Invasive
Mechanic
al
Ventilatio
n (within
24 hrs of
admission
)

16.2

No. of
Patient
put on
Non
Invasive
Mechanic
al
Ventilatio
n (after
24 hrs of
admission
)

Mean
duration
of Non
Invasive
mechanic
al
Ventilatio
n

16.3
16.4 TOTAL

17

17.1

Trepo
rt
regar
ding
Temp
orary
pace
maker
insert
ion

No. of
Temporar
y
pacemake
r inserted
(within 24
hrs of
admission
)

No. of
Temporar
y
pacemake
r inserted
(after 24
hrs of
admission
)

17.2
17.4 TOTAL

18 Total No. of Lumbar Puncture done

Report regarding Outcome of Patients

19 Report regarding referral
19.1 No. of patients Referred out (within 24 hrs of admission)
0
19.2 No. of patients Referred out (after 24 hrs of admission)
0
19.3 Total No. o
0
0
0
0
0
0
20 Report regarding LAMA (Leave against Medical Advice)
20.1 No. of patients LAMA (within 24 hrs of admission)
0
20.2 No. of patients LAMA (after 24 hrs of admission)
0
20.3 Total No. o
0
0
0
0
0
0
21 Report regarding patient Discharged cured/ relieved / Transfer to General ward of same hos
21.1 Within 24 hrs of admission
0
21.2 After 24 hrs of admission
0
21.3 Total No. o
0
0
0
0
0
0
22 Report regarding Absconded patient
22.1 No. of patients absconded (within 24 hrs of admission)
0
22.2 No. of patients absconded (after 24 hrs of admission)
0
22.3 Total no. o
0
0
0
0
0
0
23 Report regarding Patient's death
23.1 No. of patients Died (within 24 hrs of admission)
0
23.2 No. of patients Died (after 24 hrs of admission)
0
23.3 Total No. o
0
0
0
0
0
0
Report regarding Patients APACHE scoring and regarding Mechanical & Non- Mechanical Ventilation

24 Total No. of Patient for whom APACHE II Score calculated

25 OUTCOME PA
This Month
Survived
Died
Under T/t
25.1 No. of Patient with APACHE II score calculated
25.2 No. of patient with APACHE II score 0-4
25.3 No. of patient with APACHE II score 5-9
25.4 No. of patient with APACHE II score 10-14
25.5 No. of patient with APACHE II score 15-19
25.6 No. of patient with APACHE II score 20-24
25.7 No. of patient with APACHE II score 25-29
25.8 No. of patient with APACHE II score 29-34
25.9 No. of patient with APACHE II score >34
25.1 TOTAL
0
0
0
26 Outcome of Invasive Mechanical Ventilation
27 Outcome of Non Invasive Mechanical Ventilation
28 Bed Turnover Rate (BTR)
29 In-patient Bed Occupancy Rate (BOR)
30 Average Le5-6- Days
Signature of In-charge, CCU / HDU

0
Total
0
0
0
0
0
0
0
0
0
0
0
0

Annexure I

ya Bhavan every month]

Cumulative this year

Cumulative Since Inception

ANM PNM Total M

Cumulative this year

Cumulative Since Inception

ANM PNM Total M

0

0
0
0

0
0
eneral ward of same hospital

0
Mechanical Ventilation

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
Cumulative this year
Survived
Died

Under T/t

Cumulative Since Inception

Survived

Total
0
0
0
0
0
0
0
0
0
0
0
0

0
0

Signature of MSVP / Super

Since Inception

ANM PNM

Total

ANM PNM

Total

Since Inception

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0
0

Since Inception
Died

Under T/t

ignature of MSVP / Superintendent

Total
0
0
0
0
0
0
0
0
0
0
0
0

Manpower Status of CCU / HDU

Annexure II

[This format should be available in all CCU & HDU and send report to Swasthya Bhavan every month]
1 Name of HoD.M (Sadar) Hospital, Purulia
2 Name of SuDr.Nilanjana Sen
3 Phone no. 9.4E+009
4 Name of Ass
Santanu Mukherjee
5 Phone no. o8.4E+009
6 E-mail ID santanu.shaang@gmail.com
7 Alternate Eccudmsh@gmail.com
8 Name of Sup
Dr.P.K Mukherjee
8.1 Phone no. o9.4E+009
8.2 E-mail ID occudmsh@gmail.com
8.3 Alternate Eccudmsh@gmail.com
9 Name of Sup
Dr.K Bose
9.1 Phone no. o9.4E+009
9.2 E-mail ID oN/A
9.3 Alternate EN/A
10 Name of tr Mobile No. Original Posting
10.1 Dr.A Sengu 8.9E+009
10.2 Dr.S.S Das 9.5E+009
10.3 Dr.T.K Mand9.7E+009
10.4 Dr Santanu 9.4E+009
10.5
10.6
10.7
10.8
10.9
10.1
10.11
10.12
10.13
10.14
10.15
11 Name of traMobile No. Original Posting
11.1 Dipali Pal 8.9E+009
11.2 Sraddha Pa 9.3E+009
11.3 Tanushree 9.4E+009
11.4 Santoshi Ch9.9E+009
11.5
11.6
11.7
11.8
11.9
11.1
11.11

11.12
11.13
11.14
11.15
11.16
11.17
11.18
11.19
11.2
11.21
11.22
11.23
11.24
11.25
12 Name of tr Mobile No. Original Posting
12.1
12.2
12.3
12.4
12.5
Number of House keeping staff present (Dedicated for CCU)
Signature of In-charge, CCU / HDSignature of MSVP / Superintendent

nnexure II

ya Bhavan every month]

Patient Profile Report of CCU / HDU

Sl. No.

Patient Na M =
1 Jaydeep chtM
2 CharamoniPNM
3 Rubi bibi PNM
4 Prabati maPNM
5 Rabiswar sC
6 Anil chandrM
7 Rebkha bhaF
8 Rebkha bauF
9 Arcana majPNM
10 Rita bauri PNM
11 Suji mahatF
12 Juthi sarkarF
13 Suresh ku M
14 Mandira mu
F
15 Sarbeswar M
16 Tumpa bagd
PNM
17 Lagani ha PNM
18 Sujan das M
19 Debasing m
M
20 Paul sen F
21 Meru bauriF
22 Prabati maF
23 Thandi kalPNM

Annexure III
2 = Expired
2 = Referred in from other
Govt. Hospital
Male, Age
F = Female, C = Child
Date
(<12
of yr),
Ad 3ANM
= Ante
Date
Natal
of Ou
Mother, PNM =
= Transfer
3 = Referred in from other
Private out
Hospital
4 = Leave1 Against
40
1 1.07.15
4.7.15 Medical Advice (L
1 1.7.15
1 3.7.15
22
1 2.7.15
1 3.7.15
25
1 2.7.15
1 4.7.15
9
1 3.7.15
1 6.7.15
71
1 3.7.15
1 5.7.15
76
1 3.7.15
2 12.7.15
22
1 3.7.15.
1 10.7.15
19
1 4.7.15
1 6.7.15
22
1 4.7.15
1 6.7.15
65
1 4.7.15
1 26.7.15
79
1 5.7.15
3 12.7.15
50
1 5.7.15
3 12.7.15
65
1 6.7.15
1 6.7.15
50
1 6.7.15
1 9.7.15
20
1 6.7.15
1 8.7.15
25
1 6.7.15
1 8.7.15
55
1 7.7.15
1 20.7.15
27
1 8.7.15
1 11.7.15
70
1 8.7.15
1 11.7.15
62
1 9.7.15
1 10.7.15
25
1 10.7.15
2 16.7.15
30
1 10.7.15
1 10.7.15

Invasive
Mechanical
Non
- invasive
Ventillation
Mechanical
given
(Mention only
given
Yes(Mention
/ No)
only Yes /
Diagnosis
Co-morbid
(Mention
condition
Main
Clinical
Diagnosis)
(ifVentillation
any)
hanging with psychatric
LUCS
Respiratory distress
LUCS
malaria PF positive
T2 DMwith gangrenous foot
Cardiovascu
CVA
Y
laperotomy
LUCS with eclampsia
LUCS with high BP
laperotomy
Y
Heamatomeasis with melena
laperotomy followed by temporary colostomy
Chest pain
snake bite
LUCS with eclampsia
post partum eclampsia
open cholecycestectomy
pain abdomen with vomiting
Respiratory distress with cough
Inferior wall MI
LUCS with high BP
CRF with post op subtotal hystectomy