Epic Reporting Request Form

Use this form to submit a request to create a new or update an existing Epic Report. Submission of this form will automatically create an IS Service Request and be routed to the proper IS resources.

DO NOT include any Protected Health Information (PHI) on this form.

By checking this box, I am verifying that I am an Authorized Requestor in a manager/director role or a designated authorized requestor approved to receive this information. *

Confirm

Requestor's full name: *

Requestor's Dept/Location: *

Requestor's Employee ID: *

Requestor's phone number: *

Requestor's title: *

Is this request for a new report or a modification to an existing report? *

New Report

Existing Report

If this is a modification to an existing report please enter the report name (valid report name is required, "n/a" is not a valid response): *

Do similar reports already exist? *

Yes

No

If similar reports exists, please provide an example: *

Do you currently have access/rights to this report: *

Yes

No

Do you have the authority to request this modification? *

Yes

No

Date of submission: * +

Production Change needed by (date): * +

Change requested: (Please explain the changes you are requesting to this report . ie Request is to create a new report that lists out all patients seen in the office in the past six months) *

Reason for change: (What are the reasons for requesting this change ? ie The change requested will show us patient charges and payments so we can better monitor our financial position. It will show our patient workflow and throughput ) *

Change Type: *

Change Priority: *

Change Impact: *

What specifically are you going to do with the data? (Please explain what the data is going to be used for. ie The data will be utilized by the Nurse Manager to ensure nurse staffing levels are sufficient for bedded patients, The Practice Manager can see the open encounters for each physician in the practice.) *

What information needs to be included in the report? (List the data elements you need ie patient, order id , mrn, cpt code, procedure, provider etc) *

Group By: (How should the results be sorted or grouped ? ie service area, cpt code, admit date, dicharge date etc. If there are multiple grouping levels please list the order of the groups from first to last. ie Service Area, Provider, CPT Code etc. Are summaries for the groups needed ? If so, please list the summary/totals/average/counts you require) *

Criteria:(Which records qualify to be included on the report ? ie All inpatients that have been discharged within the last month that were at least 60 years old and born in August) *

Date Range (What date range is need for the report ? ie Month Begin(MB), Month End (ME),Year Begin (YB) ,Prior MonthEnd (MB-1) ,Yesterday (T-1) etc.) *

How do we test/validate this report? (Please provide examples for us to test the report. ie Accounts, Patients, MRN's that you are expecting to be on the report results) *

Who needs access to this data/report? *

How often does this data/report need to run? *

What is the output format needed for this report? *

Additional comments or details: