Texas Department Of State Health Services Annual Report

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T
D
S
H
S
EXAS
EPARTMENT OF
TATE
EALTH
ERVICES
DAVID L. LAKEY, M.D.
P.O. Box 149347
COMMISSIONER
Austin, Texas 78714-9347
1-888-963-7111
TTY: 1-800-735-2989
ASC ANNUAL REPORT
This report must be submitted annually. The date of submission is based on the facility’s license expiration month.
The report should not be submitted with the license renewal form. Please enter the total number of each of the
following events that have occurred at your facility within the reporting period shown below. Reports should be
mailed to: Gina Smith, Department of State Health Services, Facility Licensing Group, Delivery Code 2835, PO
Box 149347, Austin, Texas 78714-9347 or faxed to (512) 834-4514.
Facility Name: _____________________________
License Number: _____________
Month Facility License Expires: _____________
12-month reporting period covered by this report: From ________________ To ________________
Contact person’s name and Telephone number: ______________________________________________
Fax Number: __________________________ Email address: ___________________________________
Reportable Incidents
Totals
Total number of deaths of a patient while under the care of the ASC
Total number of patient development of complications within 24 hours of discharge
from the ASC resulting in admission to a hospital
Total number of transfers of a patient to a hospital
Total number of patient stays exceeding 23 hours
Total number of thefts of drugs and/or diversion of controlled drugs
Total occurrences of fire in the ASC
What was the average length of stay during the reporting period (average length of stay = from time anesthesia
is administered or procedure is started to time patient is discharged)?
_______________
Please check each type of procedure performed at the ASC and include total numbers of procedures
performed:
Abortion ________
General ________
Otolaryngology ________
Cardiovascular ________
Neurological ________
Pain Management ________
Chiropractic ________
OB/GYN ________
Plastic ________
Endoscopy ________
Ophthalmology ________
Thoracic _________
Foot ________
Oral ________
Urology ________
Gastroenterology ________
Orthopedic ________
Other (Specify) _____________________________ ________
Revised 10/5/12

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