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Discrepancy Report

Section 1 is to be completed by the organization submitting this form. The requested information regarding the affected hospitals must be provided in Section 4 in order to complete the HCAHPS Discrepancy Report. THIS FORM MUST BE SUBMITTED ONLINE (www.hcahpsonline.org). All required fields are indicated with an asterisk (*).

1. General Information

Unique ID     Submission Date     1a. Name of Organization submitting the Discrepancy Report
904 5/20/2012

1b. Type of Organization: *


   


2. Contact Person for this Discrepancy Report (Confirmation email will be sent to the Contact Person.)

2a. First Name:*
 2c. Last Name:*
2d. Mailing Address 1:*
 2e. Mailing Address 2:
2f. City:*
 2g. State:*
 2h. Zip Code:*(xxxxx or xxxxx-xxxx)
2i. Telephone:*(xxx-xxx-xxxx)
 EXT:
 2j. Fax Number:(xxx-xxx-xxxx)
2k. Email*

3. Information about the Discrepancy

3a. Description of the discrepancy: *
3b. Description of how the discrepancy was identified: *
3c. Description of the Corrective Action to fix the discrepancy, including estimated time for implementation: *
3d. Additional information that would be helpful that has not been included above: *


4. List of Hospitals Applicable to this Discrepancy

4a. Total number of Affected Hospitals: *

4b. Add the information for the affected hospitals by populating the following 10 fields. A hospital may be added more
than once if there are multiple time frames for the hospital. It is important that the affects of the Discrepancy Report
are quantified, however "unknown" will be accepted as a valid response.

Name of Hospital *
 CCN *
Hospital Contact Name *
 Email Address for the Hospital Contact *
Number of Eligible Discharges Affected *
 Average number of Eligible Discharges per month *
Count of Sampled Patients affected *
 Average number of surveys administered per month (sampled patients) *
Time frame affected: Begin Date *
v
Time frame affected: End Date *
v



Total
Affected
Name of Hospital
CCN
Hospital
Contact Name
Email Address for
the Hospital Contact
Number of Eligible
Discharges Affected
Average number
of Eligible
Discharges per month
Count of Sampled
Patients affected
Average number of
surveys administered
per month
(sampled patients)
Time frame
affected: Begin Date
Time frame
affected: End Date
No data to display