PCMH Patient Diversity Report

A reporting form to compile patient demographics for PCMH reporting, including race, ethnicity, preferred language, gender identity, and sexual orientation.

Reporting Context

• Reporting Period Start Date
• Reporting Period End Date
• Reporting Source
• Source Details

Patient Demographic Summary

• Total Patients Included
• Race Categories Reported
• Ethnicity Categories Reported
• Preferred Languages Reported

Identity Measures

• Was gender identity collected?
• Gender Identity Categories
• Was sexual orientation collected?
• Sexual Orientation Categories

Data Quality and Reconciliation

• Missing Demographic Fields
• Data Quality Notes
  Describe any reconciliation issues, duplicate records, or estimation methods used in the report.
• Reviewed By
  Optional reviewer name or role for internal audit trail.
• Review Date

Consent and Submission

• I understand this form may include sensitive demographic information and will be used only for reporting and quality improvement.
• Consent to include this data in the PCMH diversity report
• Submission Notes
  Add any final context needed for the audit trail or downstream reporting.