Data Analytics Center Report Request Form
Please email this to servicedesk@uphs.upenn.edu and in the subject line please put “Data
Analytics Center Report Request”. All items with the red * are required to be completed.
V1.0 2014-10
Date:
_____________
Requester Contact Information*
Name:
________________________________
Department:
________________________________
Email (UPHS or PSOM):
__________________________ Phone: _______________
Previous Report Name / Ticket #:
________________________
Request Approved By:
________________________________
Request Title*:
______________________________________
Purpose*: Please provide specific details on the objectives or abstract of your request. This will
better help us meet your specific needs.
Type of Analysis* (Please indicate the appropriate type):
Compliance, QA, Patient Care
Funded IRB Approved Research (attach IRB Approval and Protocol)
Non-funded IRB Approved Research (attach IRB Approval and Protocol)
Preparatory Research
Professional Billing
Other (Describe):
Research Program - Is the PI performing this study for a thesis for a mentored degree
program, eg. the MPH, MSCE, MSHP, MSME, or PhD?
YES NO
Expected Report Delivery Date:
______________________
Report Format (e.g. Excel, flat file, PDF, etc):
______________________
Report Frequency - Ambulatory Clinical Reports Only ______________________
One-Time Ad-Hoc Scheduled
Data Analytics Center Report Request Form
Please email this to servicedesk@uphs.upenn.edu and in the subject line please put “Data
Analytics Center Report Request”. All items with the red * are required to be completed.
V1.0 2014-10
For schedule reports how often:
Who will the report get distributed to (email address):
Define Parameters Required*
Note: The more specific you can be the better our team will be able to meet your
needs in an expedited manner. If you are not specific in your criteria(s), the request
may be denied and delay the process.
Criteria Display? Description / Exclusions / Limitations / Filters
MRN
Visit ID
Patient Class(es)
Please select only which
class(es) you will need.
Inpatient
Outpatient
Emergency
Age or DOB ranges
Gender
Race
Department(s)
Provide department
numbers not just names.
Provider(s)
Provide ID’s not just
names.
Date(s)
Include in the specific
range and date types (eg,
admit, order, result)
Procedure
Please include the specific
procedure codes. (ICD9 is
preferred for inpatient)
Diagnosis
Please include the specific
ICD-9 codes including all
decimal points. Do not
simply include ranges or
wildcards.
Orders
Medication
Please list as it is ordered
within the UPHS EMR’s –
medication id’s preferred
Data Analytics Center Report Request Form
Please email this to servicedesk@uphs.upenn.edu and in the subject line please put “Data
Analytics Center Report Request”. All items with the red * are required to be completed.
V1.0 2014-10
Lab Result
Please list the lab as it is ordered within the UPHS EMR’s.
Other
Other
Other
Other
Other
Fields to display on report
Data calculations needed (e.g. average, sum, etc):
_______________________________
Data Grouping (e.g. by patient, by day, by procedure, by Department, etc):
______________
Report Layout (draw out/describe as expected):
__________________________________
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