> ## 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 User Guide

> Version: 1.0.0 Last Updated: 2026-05-18 Module: CL (Clinical & EHR) Spec: CL-15

**Version:** 1.0.0\
**Last Updated:** 2026-05-18\
**Module:** CL (Clinical & EHR)\
**Spec:** CL-15

## Incident reporting deadline source

CL-15 supports a configurable **incident deadline track** (`cl_module_settings.incident_deadline_track`) so each facility can align with 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 contract (Medicaid).                                                                            | AHCCCS Medical Policy Manual (AMPM) Policy 961 — Quality Management / Incident Reporting |
| `dual`              | Facilities subject to both AZDHS licensure and AHCCCS contracts. The system uses the **earliest** of the two deadlines per incident. | Policy 961 + AZDHS rules                                                                 |

### Activation checklist

1. **Default is `azdhs`.** Do not change unless the org-admin has confirmed scope with Legal/Compliance.
2. **AHCCCS or dual track requires legal verification of timeframes.** Record the verification (signer, date, attached memo) in `docs/compliance/REGULATORY_COMPLIANCE_TRACKER.md` under CL-15 Open Question Q4 before flipping the switch.
3. **Business-day config** (`incident_business_day_config`) supports weekday-only exclusion in this release. Holiday calendars are deferred per CONTEXT.md.
4. **Sentinel events** (`incident_sentinel_options`) inherit the parent deadline but can be configured for immediate alerting through PF-10.
5. **Audit logging.** All changes to the dual-track fields are recorded in `pf_audit_logs` (action `cl_module_settings.incident_track.update`).

### Operational notes

* Switching tracks does **not** retroactively recalculate existing incident deadlines; only incidents created after the change use the new track.
* PF-10 alert thresholds (`incident_deadline_alert_minutes`) are shared across tracks.
* The setting UI lives at **CL Settings → Incident reporting** (`/cl/settings`).

## Clinical audit report

* Report type `clinical_audit` aggregates break-glass access, accounting of disclosures, documentation timeliness, consent, and risk screening dimensions over a rolling 30-day window.
* Dimensions are selected per-definition via checkboxes in the Report Definition dialog and stored in `cl_report_definitions.filters.audit_dimensions`.
* Report runs are visible in **CL → Report History** and write summary counts to `cl_report_runs.result_summary`. Full per-dimension drill-down ships with T-COMP-3.

## Quality measure reports (HEDIS / CARF)

* `hedis` and `carf` report types now compute a lightweight aggregate from `cl_outcome_measures` over the previous 12 months on each run.
* The aggregate exposes `denominator`, `significant_change_count`, `by_instrument`, and `by_severity` in `result_summary`.
* Full NCQA HEDIS conformance (denominator/numerator/exclusions per measure, PF-70 value sets) is tracked under **T-COMP-2** and remains pending.

## CARF readiness dashboard

* Route: `/cl/carf-readiness` (permission `cl.report_definitions.view`).
* Data source: GR-08 via the read-only `@/platform/governance` contract (`useCarfReadiness`). The CL core does not import from `@/cores/gr`.
* Empty state: "No CARF accreditation data. Add accreditations in Governance."