The Monthly Data Form by Facility form collects process measure and outcome data for a single month. Data may be entered for any month up to the prior month, provided a Facility form has also been submitted for the same year.
A printable version of the Monthly Data Form by Facility form is available for your workflow processes and should not be submitted to the ACR.
There are several dependencies and requirements for the form:
A Facility form must exist for the same year as the Monthly Data Form by Facility.
You may not restore a cancelled monthly form until an annual Facility Form has been submitted for the same year. If the Facility form's status is Cancelled or In Progress, the Restore link will not appear for the cancelled Monthly Data Form by Facility.
You may not cancel a Facility form until all monthly forms have been cancelled for the same year.
You cannot enter more than one monthly form for a given facility, year and month.
A Monthly Data Form by Facility cannot be used for MIPS (formerly PQRS) reporting.
When completing the form be sure to follow the Manual Data Entry guidelines for working with online forms. More detailed information on the data to be entered is available in the GRID Data Dictionary. Complete each of the sections, as follows:
This field is filled in automatically, as determined by the user’s profile
Month / Year
Enter the month and year for which you will be entering data.
If you checked Not Applicable for certain procedures in the Volume section of the Facility form then the corresponding fields on this form are disabled.
For patient wait times, include outpatient registration time and exams that are cross-read prior to the final report. Enter turnaround report times as hours, and all other time values as minutes.
If you checked Not Applicable for certain procedures in the Volume section of the Facility form then the corresponding fields on this form are disabled. If your facility participates at the Green Level, then all fields in this section are disabled.
Name of person who completed this paper form
If this name has not been previously entered for this field for a previous GRID form, select Add New and enter the person’s first and last name. In the future, the name will appear in the drop-down list for this field. If the name has been previously entered, click the arrow and select it from the drop-down list.
To delete a name from the list, select it and then click the Delete Person button.
Name of person submitting form
These fields are filled in automatically.
Click the Submit button. You must correct any errors before the form will be accepted. If no errors are detected, a confirmation message appears and the form moves to Completed status.
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Monthly Data by Physician