We have an eCQM client that is planning to collect and submit data to meet the IQR and MU requirement for PC-01. We have found that based on the information provided in the EMR that no cases are falling into the denominator.

The main problem seems to be that all the files lack the required entry for Physical Exam Performed: Time of Delivery. The following is required for a case to fall into the PC-01 Denominator. Both physical exams must be present in the file, and the Gestational Age exam must start BEFORE the start of the Time of Delivery exam by less than one day.
• Physical Exam, Performed: Estimated Gestational Age at Delivery:
• (result >= 37 week(s))
• (result < 39 week(s))
• starts less than one day before the start of
• Physical Exam Performed: Time of Delivery
• starts during IP Encounter
This is not good data but it is accurately reflecting what the EMR and the facility currently are collecting. Is this sufficient to meet the requirement of successful submission along with completing the Zero Denominator declaration?