Exhibit 6-3
COMMUNITY HEALTH SERVICES INVENTORY
WORKSHEET

Primary Care Office Information

  1. Practice Name: _____________________________________________________
    Address: __________________________________________________________
    _________________________________________________________________
    Phone: ___________________________________________________________

  2. Personnel
    1. Physicians/Mid-Level Providers:
      Name Age Specialty
      _______________________ ______ ___________________
      _______________________ ______ ___________________
      _______________________ ______ ___________________
      _______________________ ______ ___________________
      _______________________ ______ ___________________
      _______________________ ______ ___________________
      _______________________ ______ ___________________
      _______________________ ______ ___________________

Office Staff

  1. Office Manager
    (Name) ______________________________________________________________
  2. Number of Registered Nurses (RNs) ______________
  3. Number of Licensed Practical Nurses (LPNs) ____________
  4. Number of other staff ______________
  5. Number of Receptionists/Billing Clerks/Secretaries __________
  6. Number of Lab/X-Ray Technicians __________
  7. Number of Other(s) (list) ________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
  8. Volume
    1. Approximate number patient visits/week for the practice __________
    2. Number of OB deliveries/year/practice __________
  9. LAB/X-RAY
    1. What X-Ray facilities are available in the office?

    2. Which laboratory tests are done in office?

    3. Where are other lab tests sent?
      To local hospital __________
      To "reference" lab __________
  10. Needs and Trends (For discussion with medical providers, etc.)
    1. What are the current, important health needs of your community?
    2. What are the likely future influences on the health care of your community?

Preventive Services and Community Health Education

  1. Community Education
    1. Does the hospital or other source provide health education for the following?
      Topic   Source(s)
      Prenatal Classes Yes ____ No ____ _________
      Parenting Skills Yes ____ No ____ _________
      Diabetic Education Yes ____ No ____ _________
      Occupational Health Yes ____ No ____ _________
      Hypertension Education Yes ____ No ____ _________
      Cancer Screening Education Yes ____ No ____ _________
      AIDS Education Yes ____ No ____ _________
      CPR Classes Yes ____ No ____ _________
      Heart Disease Risk Reduction Yes ____ No ____ _________
      Contraception Advice and
      Prescription       		Yes ____ No ____ _________
      Other(s) Yes ____ No ____ _________
    2. What methods of health education and prevention are used?
      Group Classes Yes ____ No ____
      Radio "Spots" Yes ____ No ____
      TV "Spots" Yes ____ No ____
      Newspaper Columns Poster Campaigns Yes ____ No ____
      Joint Projects with:
        Schools Yes ____ No ____
        Medical Offices Yes ____ No ____
        Work Sites Yes ____ No ____
        Public Health Dept. Yes ____ No ____
  2. Preventive/Screening Services
    1. Does the hospital, or other community source, provide:
      Service   Source
      Mammography Yes ____ No ____ ________
      Blood Pressure Checks Yes ____ No ____ ________
      Cholesterol Screening Yes ____ No ____ ________
      Colorectal Cancer Screening Yes ____ No ____ ________
      Diabetes Screening Yes ____ No ____ ________
      Immunization Services Yes ____ No ____ ________
  3. Needs and Trends (For discussion with medical providers, health educators, etc.)
    1. What are the unmet needs of your community for disease prevention and screening services?

    2. What future trends are likely to influence the availability of preventive services in your community?

Other Community Health Services

  1. How many nursing homes are in your community?
      __________
    Number of Beds __________
  2. How many beds are provided?
    "Skilled" care __________
    "Intermediate" care __________
  3. Is there a Residential Care Facility? Yes _______ No _______
  4. Please estimate the numbers of health care providers engaged in the listed services in your community. If the service does not exist, write "none."
    Service Number of Personnel
    Home Health Care _________________
    Public Health Department _________________
    Dentists _________________
    Chiropractors _________________
    Mental Health Counselors _________________
    Chemical Dependency Services _________________

Health Care For Children

  1. Hospital Care
    1. Number of Admissions during last three years ages 1-12 _____________
    2. Is there a separate ward or unit usually for children inpatients? Yes _____ No _____
    3. Are there nursing staff that are designated as pediatric staff? Yes _____ No _____
    4. Is there an effort to encourage nursing staff to participate in education programs in pediatric nursing? Yes _____ No _____
    5. Do you have an inventory of medical equipment for pediatric care? Yes _____ No _____
  2. Transfer of Care
    1. Is there a defined relationship with a pediatric hospital or referral? Yes _____ No _____
  3. Are there difficulties in care for children with chronic disease/developmental disability? Yes _____ No _____
    If Yes, please describe the problems:
  4. Needs and Trends (for discussion with those involved in care of children)
    1. What are the unmet needs of your community for the health care of children?

    2. What are the future trends which may influence the health care of children in your community?

Medical Staff Organization

  1. Physician
    1. Active (Physicians who regularly admit patients)
      Last Name Age Specialty
      ______________________ _______ _________________________
      ______________________ _______ _________________________
      ______________________ _______ _________________________
      ______________________ _______ _________________________
      ______________________ _______ _________________________
      ______________________ _______ _________________________
      ______________________ _______ _________________________

    2. Courtesy (consulting)
      Last Name Age Specialty
      ______________________ _______ _________________________
      ______________________ _______ _________________________
      ______________________ _______ _________________________
      ______________________ _______ _________________________
  2. Is there a defined medical staff organization at the hospital? Yes ___ No ____

    If Yes:

    1. Is there a set of officers? Yes _____ No _____
    2. How frequently does the staff meet? __________________
    3. Is there a written set of bylaws and requirements for the medical staff? __________________
    4. Is there a written process for removing a physician's hospital privileges? __________________
  3. Is there a hospital privileges/ credentials policy?   _________________
    If Yes, is there a privileges/ credentials committee? __________________
    Have privileges to a physician been denied in the last five years? __________________
  4. Does the medical staff have a defined or routine mechanism to interface with:
    Hospital Administrator __________________
    Director of Nursing __________________
    Hospital Board __________________
  5. Needs and Trends (for discussion with medical staff)

    1. What are the unmet needs regarding medical staff organization and relationships?

    2. What future trends may influence the medical staff composition, organization, and relationships with other community groups?

Obstetrical Services

  1. Prenatal Care
    1. Number of physicians providing prenatal care __________
    2. Number of other professionals providing prenatal care __________
    3. Are there exclusions from OB care in your community?
    (e.g., Medicaid, no-pay patients)    		 Yes _____ No _____
  2. Hospital Care
    1. Number of physicians delivering babies __________
    2. Are there obstetrical nurses who work specifically in labor and delivery? Yes _____ No _____
    3. Number of deliveries per year (average) __________
      Number Infants < 2500 grams for last 3 years __________
      Number Infants < 1500 grams for last 3 years __________
      Number of neonatal deaths for last 3 years __________
    4 a) Approximately what percent of labors are followed
    with electronic fetal monitoring?    		 __________
    4 b) Approximately what percent of labors are followed
    with regular oscultation of heart tones?    		 __________
  3. Cesarean Section Capability
    1. Number of physicians performing C-sections __________
    2. Number of C-sections during last 3 years __________
    3. How is anesthesia coverage arranged?  
    4. Can a C-section be initiated within 30 minutes of recognizing
    an indication for surgery?    		 Yes _____ No _____
  4. Referrals of Obstetrical Patients
    1. Number of annual referrals (pre-partum) __________
    2. Number intrapartum (in labor) transfers per year __________
    3. Is there a clearly recognized hospital or physician group to
    which intrapartum patients in need of transfer are referred?    		 Yes _____ No _____
    4. Are there common problems with intrapartum transfer? Yes _____ No _____

    a. If Yes, what are they?

    		  
  5. Quality Assurance
    1. Is there a defined QA activity around OB care? Yes _____ No _____
    If Yes, please describe.
    2. Is there specific obstetrical continuing education for
    nursing staff?    		 Yes _____ No _____
  6. Needs and trends (for discussion with medical staff involved in obstetrical care)

    1. What unmet needs in obstetrical and neonatal care does your community have at present?

    2. What future trends do you see as important in your area's care for obstetric patients?

Reprinted with permission from MOUNTAIN STATES GROUP. Original publication: Healthy Futures - A Development Kit for Rural Hospitals, Chapter 6-4F, p. 143-160.

Diagnostic Technology

  1. Radiology
    1. Are consulting radiologists available? Yes _____ No _____
    If Yes, how frequently do they visit? ____________
    2. Is there electronic communication regarding X-Ray
    interpretation?    		 Yes _____ No _____
    3. In the hospital, is there availability of:
    Plain Films Yes _____ No _____
    GI Contrast Studies Yes _____ No _____
    IVP Yes _____ No _____
    Mammography Yes _____ No _____
    Abdominal Ultrasound Yes _____ No _____
    Obstetric Ultrasound Yes _____ No _____
    4. What is the availability of:
    Procedure Site Frequency
    CT Scan ____________________________ ____________________________
    MRI Scan ____________________________ ____________________________
    Isotope Scan ____________________________ ____________________________
    Stress EKG ____________________________ ____________________________
    Holter Monitor ____________________________ ____________________________
    5. Is there duplication of services between physician office
    and hospital?    		 Yes _____ No _____
    If Yes, which procedures are duplicated?
  2. Laboratory
    1. Is there duplication of service between physician's offices
    and the hospital?    		 Yes _____ No _____
    2. Do physicians utilize the hospital lab for outpatient tests or are specimens sent to "reference labs?"
    Hospital lab __________
    Reference lab __________
    Both __________
  3. Needs and Trends (for discussion with medical providers, allied health professionals, administrators, etc.)
    1. What unmet needs are there for diagnostic technologies in your community at present?

    2. What are likely future influences on the availability of diagnostic technologies?

Reprinted with permission from MOUNTAIN STATES GROUP. Original publication: Healthy Futures - A Development Kit for Rural Hospitals, Chapter 6-4F, p. 143-160.