CAHPS To submit this form online, please go to . Date Submitted: I. One DNR is required for each discrepancy reason. If you have multiple CCNs with the same discrepancy reason, please include all CCNs on one DNR. If you have more than one discrepancy reason, you will need to submit a DNR for each discrepancy reason. To complete this form, please complete the following sections: Section I—Select the affected Survey Period and the reason for the discrepancy from the drop down boxes. Section II—Enter all CCNs that are impacted by the discrepancy reason. Section III—Provide a detailed description of the discrepancy being reported for each CCN and include the number of affected patients. If you do not know the number of affected patients, please enter UNK. If the number of affected patients is not applicable, enter NA. Section IV—Include a description of the corrective action your organization has taken to address the discrepancy. Section V—Provide any additional information about the discrepancy that you feel the ICH CAHPS Coordination Team will need. PERIOD: DISCREPANCY REASON: II. Please enter your CCN number(s) for which you are filing the discrepancy. If you have multiple CCN numbers, please enter them as a comma separated list, as shown in the example below. After entering your CCN number(s), click on the “Lookup CCN #s Facility button. Do not include dashes in the CCN number. Names” Example: 111111, 222222, 333333 III. Please complete the items below in detail for each facility listed.
CAHPS To submit this form online, please go to . Date Submitted: I. One DNR is required for each discrepancy reason. If you have multiple CCNs with the same discrepancy reason, please include all CCNs on one DNR. If you have more than one discrepancy reason, you will need to submit a DNR for each discrepancy reason. To complete this form, please complete the following sections: Section I—Select the affected Survey Period and the reason for the discrepancy from the drop down boxes. Section II—Enter all CCNs that are impacted by the discrepancy reason. Section III—Provide a detailed description of the discrepancy being reported for each CCN and include the number of affected patients. If you do not know the number of affected patients, please enter UNK. If the number of affected patients is not applicable, enter NA. Section IV—Include a description of the corrective action your organization has taken to address the discrepancy. Section V—Provide any additional information about the discrepancy that you feel the ICH CAHPS Coordination Team will need. PERIOD: DISCREPANCY REASON: II. CCN #s Please enter your CCN number(s) for which you are filing the discrepancy. If you have multiple CCN numbers, please enter them as a comma separated list, as shown in the example below. After entering your CCN number(s), click on the “Lookup Facility Names” button. Do not include dashes in the CCN number. Example: 111111, 222222, 333333 III. Please complete the items below in detail for each facility listed.
ICH_SurveyAdminManual_Ver4_Feb2016.docx