Discrepancy Report
Indicate whether this report is an Initial Discrepancy Report or an Updated Discrepancy Report.
Initial Discrepancy Report * (Must be submitted within 24 hours after the discrepancy has been discovered.)
Updated Discrepancy Report * (If needed, must be submitted within two weeks of initial Discrepancy Report.)
Date of initial Discrepancy Report submission is required.
The Initial Discrepancy Report ID is required.
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
The Name of the Organization is required.
The Type of the Organization is required.
The Name of the Vendor is required.
The Type of the Organization is required.

2. Contact Person for this Discrepancy Report (Confirmation email will be sent to the Contact Person.)
First Name is required.
Last Name is required.
Mailing Address 1 is required.
City is required.
State is required.
Zip Code is required.
Telephone is required.
Email is required.

3. Information about the Discrepancy
Description of the discrepancy is required. {{2000 - model.DiscrepancyDescription.length}} characters remaining
Description of how the discrepancy was identified is required. {{2000 - model.DiscrepancyIdentified.length}} characters remaining
Description of the Corrective Action is required. {{2000 - model.CorrectiveAction.length}} characters remaining
Additional Info is required. {{2000 - model.AdditionalInfo.length}} characters remaining

4. List of Hospitals Applicable to this Discrepancy
The Number of Affected Hospitals is required.
Name of Hospital is required.
CCN is required.
Hospital Contact Name is required.
A valid Email Address is required.
Number of Eligible Discharges Affected is required.
Average number of Eligible Discharges per month is required.
Count of Sampled Patients affected is required.
Average number of surveys administered is required.
Begin Date is required.
End Date is required. End Date must be on or after Begin Date.
(click on a row in the grid to edit it)
Enter answer to equation on left.
Note: Please print completed Discrepancy Report form before submitting.