How Do Providers Collect SDOH?

Collect SDOH information verbally using a screening tool that the provider reads to the patient. Administer these screening tools in person or over the phone via a provider or patient navigator.

Collect SDOH information via a paper questionnaire that either the patient fills out or the provider completes after talking with the patient.

Collect SDOH information electronically via a tablet or online patient portal. You can collect this information directly from the patient, or via a provider.

Your electronic health record (EHR) system doesn’t have to use electronic screening tools to work with Z codes.

• If a patient completes a paper questionnaire that the provider reviews and enters into the EHR, coding professionals can review that information to support the assignment of Z codes
• Similarly, if a patient completes an electronic screening tool integrated with the EHR, then that documentation also can be reviewed to support the assignment of Z codes

When providers manually enter information from screening tools or patient visits into an EHR, it must be clear and concise so coders can assign a correct Z code.