92422 Financial and Statistical Data Report

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Overview

Public Reporting
For Quarterly Reporting Only
Monthly Reporting - 1st Qtr
Monthly Reporting - 2nd Qtr
Monthly Reporting - 3rd Qtr
Monthly Reporting - 4th Qtr

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Sheet 1: Public Reporting

Public reporting burden for this collection of information is estimated to average 1 hour. This includes the time for collecting, reviewing, and reporting the data. Response to this request for information is required in order to receive the benefits to be derived. Section 232 of the National Housing Act authorizes mortgage insurance for the development of nursing homes and intermediate care facilities. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number. While no assurance of confidentiality is pledged to respondents, HUD generally discloses this data only in response to a Freedom of Information Act request.

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Sheet 2: For Quarterly Reporting Only

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER HOSPITAL NAME HERE			ENTER FYE HERE
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) Please call your OIHCF Account Executive for any clarifications.
(B.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in yellow
(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets")
(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.
Description	Entry Label	1st Qtr	2nd Qtr	3rd Qtr	4th Qtr
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments	R06
Gross Patient Receivables
Allowance for Doubtful Accounts	R32
Net Accounts Receivable	R07
All Other Current Assets
Total Current Assets	R09
Long Term Investments	R33
Limited Use or Desginated Assets	R10
Gross Property, Plant & Equipment
Accumulated Depreciation	R11
Net Property, Plant & Equipment	R12
All Other Non-current Assets
Total Assets	R13
Accounts Payable & Accrued Expenses	H01
Current Portion of LT Debts	R14
All Other Current Liabilities
Total Current Liabilities	R15
Long Term Capital Debt	R16
All Other Long Term Liabilities
Total Long Term Liabilities
Total Liabilities	R17
Unrestricted Fund Balance	R18
Temporarily Restricted Fund Balance	R39
Restricted Fund Balance	R19
Total Net Assets
Total Net Assets + Total Liabilities
Income Statement
Net Inpatient Revenue (1) (6)	H02
Net Outpatient Revenue (1) (6)	H03
Total Net Patient Revenue (1)	R20
All Other Operating Revenue
Total Operating Revenue	R21
Salaries & Wages	H05
Employee Benefits	R36
Total Supplies Expense	H04
Depreciation & Amortization Expense	R22
Interest Expense	R23
Bad Debt Expense (1)	R24
All Other Operating Expenses
Total Operating Expense	R25
Income from Operations
All Non-Operating Revenue	H06
All Non-Operating Expense	H07
Extraordinary Items & Income Taxes	R26
Net Income	R27
Unrecognized Gains/Losses	R28
Other Changes in Fund Balance (2)	R30
Net Increase/Decrease in Fund Balance
Mortage Reserve Fund
Required MRF Balance	H11
Actual MRF Balance	H12
Net Inpatient Revenue (1)
Medicare	H13
Medicaid	H14
Blue Cross	H15
Commercial Insurance	H16
HMO/Managed Care	H17
Self Pay	H18
Other	H45
Inpatient Utilization
Total Licensed Beds	H19
Total Staffed Beds	H20
Acute Medical/Surgical Service
Number of Beds	H21
Discharges	H22
Patient Days	H23
Newborn Service
Number of Beds	H24
Discharges	H25
Patient Days	H26
Other Acute Care Services
Number of Beds	H27
Discharges	H28
Patient Days	H29
Other Non-Acute Care
Number of Beds	H30
Discharges	H31
Patient Days	H32
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)	H33
ALOS (5)	H34
Non-Medicare
Case Mix Index (3)	H35
ALOS (5)	H36
All Patients
Case Mix Index (3)	H37
ALOS (5)	H38
Inpatient Cost per Discharge	H39
Outpatient Utilization
Emergency Room Visits	H40
Ambulatory Surgery	H41
Clinic Visits	H42
Other Outpatient Visits	H43
Staffing
Total Full-Time Equivalents (4)	H44
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A15-A16=A17		Yes	Yes	Yes	Yes
A14+A17+A18=A19		Yes	Yes	Yes	Yes
A19+A20+A21+A24+A25=A26		Yes	Yes	Yes	Yes
A28+A29+A30=A31		Yes	Yes	Yes	Yes
A32+A33=A34		Yes	Yes	Yes	Yes
A31+A34=A35		Yes	Yes	Yes	Yes
A36+A37+A38=A39		Yes	Yes	Yes	Yes
A35+A39=A40		Yes	Yes	Yes	Yes
Income Statement
A43+A44=A45		Yes	Yes	Yes	Yes
A45+A46=A47		Yes	Yes	Yes	Yes
A49+A50+A51+A52+A53+A54+A55=A56		Yes	Yes	Yes	Yes
A57+A59-A60-A61=A62		Yes	Yes	Yes	Yes
A62+A64+A65=A66		Yes	Yes	Yes	Yes
A72+A73+A74+A75+A76+A77+A78=A43		Yes	Yes	Yes	Yes
Various Edit Checks
R20<=R21		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25		Yes	Yes	Yes	Yes	tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted fund balance
H1+R14<=R15		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17		Yes	Yes	Yes	Yes	total current lab + LT capital debt = total liabilities
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

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Sheet 3: Monthly Reporting - 1st Qtr

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER FYE HERE
ENTER HOSPITAL NAME HERE
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) Please call your OIHCF Account Executive for any clarifications.
(B.) For the FY month that you are completing, a value must be entered for all cells highlighted in yellow
(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets")
(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.
Description	Entry Label	1st Month	2nd Month	3rd Month	Do not Use - Start New Spreadsheet
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments	R06
Gross Patient Receivables
Allowance for Doubtful Accounts	R32
Net Accounts Receivable	R07
All Other Current Assets
Total Current Assets	R09
Long Term Investments	R33
Limited Use or Desginated Assets	R10
Gross Property, Plant & Equipment
Accumulated Depreciation	R11
Net Property, Plant & Equipment	R12
All Other Non-current Assets
Total Assets	R13
Accounts Payable & Accrued Expenses	H01
Current Portion of LT Debts	R14
All Other Current Liabilities
Total Current Liabilities	R15
Long Term Capital Debt	R16
All Other Long Term Liabilities
Total Long Term Liabilities
Total Liabilities	R17
Unrestricted Fund Balance	R18
Temporarily Restricted Fund Balance	R39
Restricted Fund Balance	R19
Total Net Assets
Total Net Assets + Total Liabilities
Income Statement
Net Inpatient Revenue (1) (6)	H02
Net Outpatient Revenue (1) (6)	H03
Total Net Patient Revenue (1)	R20
All Other Operating Revenue
Total Operating Revenue	R21
Salaries & Wages	H05
Employee Benefits	R36
Total Supplies Expense	H04
Depreciation & Amortization Expense	R22
Interest Expense	R23
Bad Debt Expense (1)	R24
All Other Operating Expenses
Total Operating Expense	R25
Income from Operations
All Non-Operating Revenue	H06
All Non-Operating Expense	H07
Extraordinary Items & Income Taxes	R26
Net Income	R27
Unrecognized Gains/Losses	R28
Other Changes in Fund Balance (2)	R30
Net Increase/Decrease in Fund Balance
Mortage Reserve Fund
Required MRF Balance	H11
Actual MRF Balance	H12
Net Inpatient Revenue (1)
Medicare	H13
Medicaid	H14
Blue Cross	H15
Commercial Insurance	H16
HMO/Managed Care	H17
Self Pay	H18
Other	H45
Inpatient Utilization
Total Licensed Beds	H19
Total Staffed Beds	H20
Acute Medical/Surgical Service
Number of Beds	H21
Discharges	H22
Patient Days	H23
Newborn Service
Number of Beds	H24
Discharges	H25
Patient Days	H26
Other Acute Care Services
Number of Beds	H27
Discharges	H28
Patient Days	H29
Other Non-Acute Care
Number of Beds	H30
Discharges	H31
Patient Days	H32
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)	H33
ALOS (5)	H34
Non-Medicare
Case Mix Index (3)	H35
ALOS (5)	H36
All Patients
Case Mix Index (3)	H37
ALOS (5)	H38
Inpatient Cost per Discharge	H39
Outpatient Utilization
Emergency Room Visits	H40
Ambulatory Surgery	H41
Clinic Visits	H42
Other Outpatient Visits	H43
Staffing
Total Full-Time Equivalents (4)	H44
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A17-A18=A19		Yes	Yes	Yes	Yes
A16+A19+A20=A21		Yes	Yes	Yes	Yes
A21+A22+A23+A26+A27=A28		Yes	Yes	Yes	Yes
A30+A31+A32=A33		Yes	Yes	Yes	Yes
A34+A35=A36		Yes	Yes	Yes	Yes
A33+A36=A37		Yes	Yes	Yes	Yes
A38+A39+A40=A41		Yes	Yes	Yes	Yes
A37+A41=A42		Yes	Yes	Yes	Yes
Income Statement
A45+A46=A47		Yes	Yes	Yes	Yes
A47+A48=A49		Yes	Yes	Yes	Yes
A51+A52+A53+A54+A55+A56+A57=A58		Yes	Yes	Yes	Yes
A59+A61-A62-A63=A64		Yes	Yes	Yes	Yes
A64+A66+A67=A68		Yes	Yes	Yes	Yes
A74+A75+A76+A77+A78+A79+A80=A45		Yes	Yes	Yes	Yes
Various Edit Checks
R20<=R21		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25		Yes	Yes	Yes	Yes	tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted fund balance
H1+R14<=R15		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17		Yes	Yes	Yes	Yes	total current lab + LT capital debt = total liabilities
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

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Sheet 4: Monthly Reporting - 2nd Qtr

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER FYE HERE
ENTER HOSPITAL NAME HERE
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) Please call your OIHCF Account Executive for any clarifications.
(B.) For the FY month that you are completing, a value must be entered for all cells highlighted in yellow
(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets")
(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.
Description	Entry Label	4th Month	5th Month	6th Month	Do not Use - Start New Spreadsheet
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments	R06
Gross Patient Receivables
Allowance for Doubtful Accounts	R32
Net Accounts Receivable	R07
All Other Current Assets
Total Current Assets	R09
Long Term Investments	R33
Limited Use or Desginated Assets	R10
Gross Property, Plant & Equipment
Accumulated Depreciation	R11
Net Property, Plant & Equipment	R12
All Other Non-current Assets
Total Assets	R13
Accounts Payable & Accrued Expenses	H01
Current Portion of LT Debts	R14
All Other Current Liabilities
Total Current Liabilities	R15
Long Term Capital Debt	R16
All Other Long Term Liabilities
Total Long Term Liabilities
Total Liabilities	R17
Unrestricted Fund Balance	R18
Temporarily Restricted Fund Balance	R39
Restricted Fund Balance	R19
Total Net Assets
Total Net Assets + Total Liabilities
Income Statement
Net Inpatient Revenue (1) (6)	H02
Net Outpatient Revenue (1) (6)	H03
Total Net Patient Revenue (1)	R20
All Other Operating Revenue
Total Operating Revenue	R21
Salaries & Wages	H05
Employee Benefits	R36
Total Supplies Expense	H04
Depreciation & Amortization Expense	R22
Interest Expense	R23
Bad Debt Expense (1)	R24
All Other Operating Expenses
Total Operating Expense	R25
Income from Operations
All Non-Operating Revenue	H06
All Non-Operating Expense	H07
Extraordinary Items & Income Taxes	R26
Net Income	R27
Unrecognized Gains/Losses	R28
Other Changes in Fund Balance (2)	R30
Net Increase/Decrease in Fund Balance
Mortage Reserve Fund
Required MRF Balance	H11
Actual MRF Balance	H12
Net Inpatient Revenue (1)
Medicare	H13
Medicaid	H14
Blue Cross	H15
Commercial Insurance	H16
HMO/Managed Care	H17
Self Pay	H18
Other	H45
Inpatient Utilization
Total Licensed Beds	H19
Total Staffed Beds	H20
Acute Medical/Surgical Service
Number of Beds	H21
Discharges	H22
Patient Days	H23
Newborn Service
Number of Beds	H24
Discharges	H25
Patient Days	H26
Other Acute Care Services
Number of Beds	H27
Discharges	H28
Patient Days	H29
Other Non-Acute Care
Number of Beds	H30
Discharges	H31
Patient Days	H32
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)	H33
ALOS (5)	H34
Non-Medicare
Case Mix Index (3)	H35
ALOS (5)	H36
All Patients
Case Mix Index (3)	H37
ALOS (5)	H38
Inpatient Cost per Discharge	H39
Outpatient Utilization
Emergency Room Visits	H40
Ambulatory Surgery	H41
Clinic Visits	H42
Other Outpatient Visits	H43
Staffing
Total Full-Time Equivalents (4)	H44
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A17-A18=A19		Yes	Yes	Yes	Yes
A16+A19+A20=A21		Yes	Yes	Yes	Yes
A21+A22+A23+A26+A27=A28		Yes	Yes	Yes	Yes
A30+A31+A32=A33		Yes	Yes	Yes	Yes
A34+A35=A36		Yes	Yes	Yes	Yes
A33+A36=A37		Yes	Yes	Yes	Yes
A38+A39+A40=A41		Yes	Yes	Yes	Yes
A37+A41=A42		Yes	Yes	Yes	Yes
Income Statement
A45+A46=A47		Yes	Yes	Yes	Yes
A47+A48=A49		Yes	Yes	Yes	Yes
A51+A52+A53+A54+A55+A56+A57=A58		Yes	Yes	Yes	Yes
A59+A61-A62-A63=A64		Yes	Yes	Yes	Yes
A64+A66+A67=A68		Yes	Yes	Yes	Yes
A74+A75+A76+A77+A78+A79+A80=A45		Yes	Yes	Yes	Yes
Various Edit Checks
R20<=R21		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25		Yes	Yes	Yes	Yes	tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted fund balance
H1+R14<=R15		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17		Yes	Yes	Yes	Yes	total current lab + LT capital debt = total liabilities
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

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Sheet 5: Monthly Reporting - 3rd Qtr

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER FYE HERE
ENTER HOSPITAL NAME HERE
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) Please call your OIHCF Account Executive for any clarifications.
(B.) For the FY month that you are completing, a value must be entered for all cells highlighted in yellow
(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets")
(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.
Description	Entry Label	7th Month	8th Month	9th Month	Do not Use - Start New Spreadsheet
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments	R06
Gross Patient Receivables
Allowance for Doubtful Accounts	R32
Net Accounts Receivable	R07
All Other Current Assets
Total Current Assets	R09
Long Term Investments	R33
Limited Use or Desginated Assets	R10
Gross Property, Plant & Equipment
Accumulated Depreciation	R11
Net Property, Plant & Equipment	R12
All Other Non-current Assets
Total Assets	R13
Accounts Payable & Accrued Expenses	H01
Current Portion of LT Debts	R14
All Other Current Liabilities
Total Current Liabilities	R15
Long Term Capital Debt	R16
All Other Long Term Liabilities
Total Long Term Liabilities
Total Liabilities	R17
Unrestricted Fund Balance	R18
Temporarily Restricted Fund Balance	R39
Restricted Fund Balance	R19
Total Net Assets
Total Net Assets + Total Liabilities
Income Statement
Net Inpatient Revenue (1) (6)	H02
Net Outpatient Revenue (1) (6)	H03
Total Net Patient Revenue (1)	R20
All Other Operating Revenue
Total Operating Revenue	R21
Salaries & Wages	H05
Employee Benefits	R36
Total Supplies Expense	H04
Depreciation & Amortization Expense	R22
Interest Expense	R23
Bad Debt Expense (1)	R24
All Other Operating Expenses
Total Operating Expense	R25
Income from Operations
All Non-Operating Revenue	H06
All Non-Operating Expense	H07
Extraordinary Items & Income Taxes	R26
Net Income	R27
Unrecognized Gains/Losses	R28
Other Changes in Fund Balance (2)	R30
Net Increase/Decrease in Fund Balance
Mortage Reserve Fund
Required MRF Balance	H11
Actual MRF Balance	H12
Net Inpatient Revenue (1)
Medicare	H13
Medicaid	H14
Blue Cross	H15
Commercial Insurance	H16
HMO/Managed Care	H17
Self Pay	H18
Other	H45
Inpatient Utilization
Total Licensed Beds	H19
Total Staffed Beds	H20
Acute Medical/Surgical Service
Number of Beds	H21
Discharges	H22
Patient Days	H23
Newborn Service
Number of Beds	H24
Discharges	H25
Patient Days	H26
Other Acute Care Services
Number of Beds	H27
Discharges	H28
Patient Days	H29
Other Non-Acute Care
Number of Beds	H30
Discharges	H31
Patient Days	H32
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)	H33
ALOS (5)	H34
Non-Medicare
Case Mix Index (3)	H35
ALOS (5)	H36
All Patients
Case Mix Index (3)	H37
ALOS (5)	H38
Inpatient Cost per Discharge	H39
Outpatient Utilization
Emergency Room Visits	H40
Ambulatory Surgery	H41
Clinic Visits	H42
Other Outpatient Visits	H43
Staffing
Total Full-Time Equivalents (4)	H44
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A17-A18=A19		Yes	Yes	Yes	Yes
A16+A19+A20=A21		Yes	Yes	Yes	Yes
A21+A22+A23+A26+A27=A28		Yes	Yes	Yes	Yes
A30+A31+A32=A33		Yes	Yes	Yes	Yes
A34+A35=A36		Yes	Yes	Yes	Yes
A33+A36=A37		Yes	Yes	Yes	Yes
A38+A39+A40=A41		Yes	Yes	Yes	Yes
A37+A41=A42		Yes	Yes	Yes	Yes
Income Statement
A45+A46=A47		Yes	Yes	Yes	Yes
A47+A48=A49		Yes	Yes	Yes	Yes
A51+A52+A53+A54+A55+A56+A57=A58		Yes	Yes	Yes	Yes
A59+A61-A62-A63=A64		Yes	Yes	Yes	Yes
A64+A66+A67=A68		Yes	Yes	Yes	Yes
A74+A75+A76+A77+A78+A79+A80=A45		Yes	Yes	Yes	Yes
Various Edit Checks
R20<=R21		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25		Yes	Yes	Yes	Yes	tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted fund balance
H1+R14<=R15		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17		Yes	Yes	Yes	Yes	total current lab + LT capital debt = total liabilities
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

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Sheet 6: Monthly Reporting - 4th Qtr

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER FYE HERE
ENTER HOSPITAL NAME HERE
	If monthly reporting is required enter 1, if quarterly enter 2
Instructions:
(A.) Please call your OIHCF Account Executive for any clarifications.
(B.) For the FY month that you are completing, a value must be entered for all cells highlighted in yellow
(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no
specific line on this worksheet for it, then it should be included in "All Other Current Assets")
(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.
Description	Entry Label	10th Month	11th Month	12th Month	Do not Use - Start New Spreadsheet
		YTD	YTD	YTD	YTD
Balance Sheet
Cash & Temporary Investments	R06
Gross Patient Receivables
Allowance for Doubtful Accounts	R32
Net Accounts Receivable	R07
All Other Current Assets
Total Current Assets	R09
Long Term Investments	R33
Limited Use or Desginated Assets	R10
Gross Property, Plant & Equipment
Accumulated Depreciation	R11
Net Property, Plant & Equipment	R12
All Other Non-current Assets
Total Assets	R13
Accounts Payable & Accrued Expenses	H01
Current Portion of LT Debts	R14
All Other Current Liabilities
Total Current Liabilities	R15
Long Term Capital Debt	R16
All Other Long Term Liabilities
Total Long Term Liabilities
Total Liabilities	R17
Unrestricted Fund Balance	R18
Temporarily Restricted Fund Balance	R39
Restricted Fund Balance	R19
Total Net Assets
Total Net Assets + Total Liabilities
Income Statement
Net Inpatient Revenue (1) (6)	H02
Net Outpatient Revenue (1) (6)	H03
Total Net Patient Revenue (1)	R20
All Other Operating Revenue
Total Operating Revenue	R21
Salaries & Wages	H05
Employee Benefits	R36
Total Supplies Expense	H04
Depreciation & Amortization Expense	R22
Interest Expense	R23
Bad Debt Expense (1)	R24
All Other Operating Expenses
Total Operating Expense	R25
Income from Operations
All Non-Operating Revenue	H06
All Non-Operating Expense	H07
Extraordinary Items & Income Taxes	R26
Net Income	R27
Unrecognized Gains/Losses	R28
Other Changes in Fund Balance (2)	R30
Net Increase/Decrease in Fund Balance
Mortage Reserve Fund
Required MRF Balance	H11
Actual MRF Balance	H12
Net Inpatient Revenue (1)
Medicare	H13
Medicaid	H14
Blue Cross	H15
Commercial Insurance	H16
HMO/Managed Care	H17
Self Pay	H18
Other	H45
Inpatient Utilization
Total Licensed Beds	H19
Total Staffed Beds	H20
Acute Medical/Surgical Service
Number of Beds	H21
Discharges	H22
Patient Days	H23
Newborn Service
Number of Beds	H24
Discharges	H25
Patient Days	H26
Other Acute Care Services
Number of Beds	H27
Discharges	H28
Patient Days	H29
Other Non-Acute Care
Number of Beds	H30
Discharges	H31
Patient Days	H32
Acute Care Only (Excl. Newborn)
Medicare
Case Mix Index (3)	H33
ALOS (5)	H34
Non-Medicare
Case Mix Index (3)	H35
ALOS (5)	H36
All Patients
Case Mix Index (3)	H37
ALOS (5)	H38
Inpatient Cost per Discharge	H39
Outpatient Utilization
Emergency Room Visits	H40
Ambulatory Surgery	H41
Clinic Visits	H42
Other Outpatient Visits	H43
Staffing
Total Full-Time Equivalents (4)	H44
Footnotes:
(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.
Edit Checks		Edit Satisfied?	Edit Satisfied?	Edit Satisfied?	Edit Satisfied?
Balance Sheet
A17-A18=A19		Yes	Yes	Yes	Yes
A16+A19+A20=A21		Yes	Yes	Yes	Yes
A21+A22+A23+A26+A27=A28		Yes	Yes	Yes	Yes
A30+A31+A32=A33		Yes	Yes	Yes	Yes
A34+A35=A36		Yes	Yes	Yes	Yes
A33+A36=A37		Yes	Yes	Yes	Yes
A38+A39+A40=A41		Yes	Yes	Yes	Yes
A37+A41=A42		Yes	Yes	Yes	Yes
Income Statement
A45+A46=A47		Yes	Yes	Yes	Yes
A47+A48=A49		Yes	Yes	Yes	Yes
A51+A52+A53+A54+A55+A56+A57=A58		Yes	Yes	Yes	Yes
A59+A61-A62-A63=A64		Yes	Yes	Yes	Yes
A64+A66+A67=A68		Yes	Yes	Yes	Yes
A74+A75+A76+A77+A78+A79+A80=A45		Yes	Yes	Yes	Yes
Various Edit Checks
R20<=R21		Yes	Yes	Yes	Yes	total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27		Yes	Yes	Yes	Yes	tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25		Yes	Yes	Yes	Yes	tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9		Yes	Yes	Yes	Yes	cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13		Yes	Yes	Yes	Yes	tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18		Yes	Yes	Yes	Yes	total assets = total liabilities + unrestricted fund balance
H1+R14<=R15		Yes	Yes	Yes	Yes	AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17		Yes	Yes	Yes	Yes	total current lab + LT capital debt = total liabilities
Reasonableness Review for Cost per Discharge		#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!