Documentation Reporting Periods FAQs
All Documents Must Show Dates
|Record Review Workbook (RRWB) (PCMH Only)
- For PCMH 4B and 4C, the practice may go back 12 months (with a 2-month grace period) from the care visit related to the selection criteria to locate documentation of each item in patient medical record
- For example, if a survey tool is submitted May 31, 2015:
- Patient #1 had a care visit date on March 2, 2015.
- The practice may go back 12 months (with a 2-month grace period) to locate the data from March 2, 2015.
- For PCMH 3C, it is up to the practice to determine frequency of assessment using evidence-based guidelines.
- Policies, procedures and processes must be in place for at least 3 months prior to survey submission
- This time period is intended for practice staff to ensure a systematic approach to patient care and practice operations.
- If the documented process has been updated, the practice must provide:
- New and previous documented process or identify where changes have occurred in the updated process
- Date of update
|Reporting Periods (Rates)
- NCQA requires that reports are from a recent 3-month period (i.e., any 3-month period within the 12 months prior to survey submission).
- For example, if a survey tool is submitted August 2015, a 3-month reporting period may be:
- Between August 2014-August 2015
- A report with one year of data may be for the previous calendar year, that is, January 2014-December 2014
|Reporting Period (Log or Report)
- Refer to documentation section of specific elements in the PCMH 2014 Standards and Guidelines for minimum data documentation periods (at least one week, one month, 30-calendar-day, etc.)
- "Recent" reporting period means within 12 months prior to the survey tool submission:
- If a survey tool is submitted October 1, 2015, the documentation period for a one-month data report must be October 1, 2014-September 30, 2015
- If a full year of data is included the report submitted in October 2015, the data may be for the previous calendar year, that is, January 2014-December 2014.
|Data Comparison to Show Continuous Quality Improvement (PCMH 2014 6D or PCSP 2013 6C: Implement Continuous Quality Improvement)
REPORT = summary of results
PERFORMANCE DATA = measurable and enables data comparisons; requires a numerator, denominator and percentage.
|Meaningful Use Reporting (PCMH 2014 6F: Report Performance) (PCMH Only)
- Factor 1, Individual clinician performance results with the practice: Show Meaningful Use attestation transmission for each physician to show transmission of clinical quality measures to CMS
- If a survey tool is submitted the third or fourth quarter of 2015, the practice may submit Meaningful Use data (or an attestation) from January 2014 -- December 2014.
- Data or an attestation from 2013 is not acceptable.