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Patient Demographics, Capacity and Referral Patterns
1.
Patient Demographics, Capacity, and Referral Patterns
1.
Facility Name:
2.
What percentage of your patients belong to each of the following
demographic categories?
None
Less than 10%
10%-33%
34%-66%
67%-99%
All
Patients under 18 years of age
None
Less than 10%
10%-33%
34%-66%
67%-99%
All
Patients over 50 years of age
None
Less than 10%
10%-33%
34%-66%
67%-99%
All
Female patients
None
Less than 10%
10%-33%
34%-66%
67%-99%
All
3.
How many
inpatient beds
are in your facility?
4.
What is your average
inpatient bed occupancy rate
at any given time?
N/A
<10%
10-33%
34%-66%
67%-90%
>90%
5.
On average, how many
outpatients (ambulatory patients)
are seen in your facility each day?
6.
How often do your
physicians
practice medicine outside their area of residency or fellowship training (for example, internists performing surgeries)?
Infrequently
Sometimes
Frequently
7.
Does your facility
refer patients to other facilities
?
Yes
No
If Yes, please list the hospitals and clinics where you refer your patients. Please also note the distance from your facility to these places.
1 / 2
50%
