Quick Reference — To record that a patient declined a screening questionnaire
To support clinical quality reporting requirements, you can indicate that a patient declined to complete a screening questionnaire along with the reason why. The reasons for declining a screening questionnaire support clinical quality measure (CQM) documentation and are backed by SNOMED codes.
Screening questionnaires marked as declined appear in the encounter summary and full encounter summary, the patient chart, the Patient Care Summary, the summary of care record, and in the Screening flowsheet.
- From the Intake stage of an encounter, click the Screening section in the checklist.
- Click the plus sign
to open the section.
The Screening window appears. - Select the screening questionnaire that you want to administer.
The questionnaire appears. - If the patient declines to answer the questions, select the reason from the menu below the questionnaire name. The reason you select and save will be visible in the Screening flowsheet.
If you previously selected the Patient declined option, the Patient refused option is preselected.
- Not indicated — Select this option when, for example, a patient returns for a follow‑up visit shortly after a previous visit when the questionnaire was completed and reviewed. This is a medical reason, which satisfies data reporting requirements.
- Not tolerated — Select this option when, for example, a patient comes in for a quick nurse visit and becomes angry or agitated when you ask the screening questions. This is a medical reason, which satisfies data reporting requirements.
- Patient refused — Select this option when, for example, a patient comes in for a quick nurse visit and declines to answer the screening questions because he's in a hurry or feels uncomfortable. This is not a medical reason, so it doesn't satisfy data reporting requirements.
- Click the Save button. (You must click the Save button in the Screening section to save your work.)