> ## Documentation Index
> Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt
> Use this file to discover all available pages before exploring further.

# Clinical Reporting & Quality Measures Expansion — User Guide

> Phase 2 & 3: dual-track incident deadlines, clinical audit report, quality measures, patient-portal QM, and CARF survey readiness.

## Overview

This guide covers the Phase 2 and Phase 3 expansion of **CL-15: Clinical Reporting & Quality Measures**. It builds on the Phase 1 base (report definitions, report runs, AZDHS incident reporting, compliance dashboards) and adds:

* **Dual-track incident deadlines** — align incident reporting timelines with AZDHS licensing and/or AHCCCS Policy 961.
* **Clinical audit report** — a single report that aggregates compliance signals across several CL modules.
* **Quality measure reports (HEDIS / CARF)** — lightweight automated aggregation from CL-10 outcomes.
* **Patient-portal quality measures** — a read-only view of a patient's measure status and follow-up deadlines.
* **CARF survey readiness** — a pre-survey checklist and readiness score sourced from Governance (GR-08).

Some items in this expansion are shipped today and some are pending; each section below states its status so you know what to expect in the UI.

## Incident reporting deadline tracks

CL-15 supports a configurable **incident deadline track** (`cl_module_settings.incident_deadline_track`) so each facility can follow the regulator that governs its contract.

| Track               | When to use                                                                                                                                                | Reference                                        |
| ------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------ |
| `azdhs` *(default)* | Arizona behavioral-health facilities licensed by AZDHS without an AHCCCS contract. Preserves CL-15 Phase 1 behavior.                                       | AZDHS R9-10 / R9-20 incident reporting timelines |
| `ahcccs`            | Facilities operating under an AHCCCS (Medicaid) contract.                                                                                                  | AHCCCS Medical Policy Manual (AMPM) Policy 961   |
| `dual`              | Facilities subject to both AZDHS licensure and an AHCCCS contract. The system computes **both** deadlines and surfaces the **earliest** for each incident. | Policy 961 + AZDHS rules                         |

**How deadlines are calculated (dual example):** for a `serious_injury` incident discovered Friday 4 pm, a dual-track org computes both an AZDHS deadline (e.g. 6 hours → Friday 10 pm) and an AHCCCS deadline (next business day → Monday), and alerts you against each.

Operational notes:

* The track is configured by an org admin at **CL Settings → Incident reporting** (`/cl/settings`). See the admin guide for the configuration and legal-verification steps.
* Switching tracks is **not retroactive** — only incidents created after the change use the new track.
* Business-day handling currently supports weekday-only exclusion; holiday calendars are deferred.

<Note>
  The `azdhs` / `ahcccs` / `dual` values are Arizona-specific for this release. When platform multi-state support (PF-96) lands, deadline logic resolves the regulator from the jurisdiction profile rather than these literal values.
</Note>

## Clinical audit report

The `clinical_audit` report type aggregates compliance signals across CL modules into one report for survey preparation and ongoing monitoring.

* **Dimensions:** break-glass access (CL-01), accounting of disclosures (CL-11), documentation timeliness (CL-04), consent status, and risk screening (CL-07).
* **Selecting dimensions:** choose the dimensions per definition via checkboxes in the Report Definition dialog; selections are stored on the report definition (`cl_report_definitions.filters`).
* **Running it:** trigger a run from **CL → Report History**; summary counts per dimension are written to `cl_report_runs.result_summary`.

<Note>
  Status: the report type, dimension selection, and aggregated summary counts are available. Full per-dimension drill-down rendering is **pending** (tracked under T5 / T-COMP-3).
</Note>

## Quality measure reports (HEDIS / CARF)

* `hedis` and `carf` report types compute a lightweight aggregate from `cl_outcome_measures` (CL-10) over the trailing 12 months on each run.
* The aggregate exposes fields such as `denominator`, `significant_change_count`, `by_instrument`, and `by_severity` in `result_summary`.

<Note>
  Status: lightweight automated aggregation is available. Full NCQA HEDIS conformance (per-measure numerator/denominator/exclusions and PF-70 value sets) is **pending** (T-COMP-2).
</Note>

## Patient portal — quality measures

Portal users can see a read-only summary of their own quality-measure status and upcoming follow-up deadlines.

* The view is **scoped to the current patient** and shows latest scores, trend direction, and upcoming follow-up dates — not raw clinical data.
* Example: a patient with PHQ-9 and GAD-7 scores in CL-10 and a follow-up appointment sees their latest values, trend, and the next follow-up date.
* **SUD privacy:** measures derived from 42 CFR Part 2 (SUD) data are gated by the patient's consent status; without the required consent, those measures are withheld.
* When no measure data exists, the page shows an empty state rather than an error.

## CARF survey readiness

* **Route:** `/cl/carf-readiness` (permission `cl.report_definitions.view`).
* **Data source:** Governance (GR-08), consumed through the read-only `@/platform/governance` contract — the Clinical core does not read Governance tables directly.
* **Empty state:** "No CARF accreditation data. Add accreditations in Governance."

<Note>
  Status: the Governance data contract is available. The dedicated CARF readiness page and route are **pending** (T10).
</Note>

## Permissions

| Action                                                              | Permission key                    |
| ------------------------------------------------------------------- | --------------------------------- |
| View / run clinical audit, HEDIS, CARF reports; view CARF readiness | `cl.report_definitions.view`      |
| Create report definitions                                           | `cl.report_definitions.create`    |
| Delete report definitions                                           | `cl.report_definitions.delete`    |
| Configure incident deadline tracks                                  | org admin on `cl_module_settings` |

<Note>
  This page documents shipped product behavior. It is not medical, legal, or
  billing advice. Verify against your organization's policies and applicable
  regulations before using it for clinical, compliance, or billing decisions.
  Protected health information (PHI) shown in the product is governed by your
  tenant's access controls and is never exposed in this documentation.
</Note>