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Run: PCMH Patient Diversity Report

PCMH Patient Diversity Report template for compiling patient demographics by reporting period, source, and identity measures. Use it to document data quality...

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Reporting Context

Reporting Period Start Date (required)

Reporting Period End Date (required)

Reporting Source (required)

Source Details

Patient Demographic Summary

Total Patients Included (required)

Race Categories Reported (required)

Ethnicity Categories Reported (required)

Preferred Languages Reported (required)

Identity Measures

Was gender identity collected? (required)

Gender Identity Categories

Was sexual orientation collected? (required)

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. (required)

Yes No N/A

Consent to include this data in the PCMH diversity report (required)

Yes No N/A

Submission Notes

Add any final context needed for the audit trail or downstream reporting.

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