The intent of the clause OR: "Communication: From Provider to Patient not done: Patient Refusal" for "Written Information Given " in Numerator is to give the opportunity for the provider receiving credit when offering the patient discharge instructions but declined by the patient. This scenario exists in the paper-based core manual and this type of information is commonly captured in notes. The eCQM doesn't specify the source of data in terms of patient refusal, however, it would create less burden for extraction of data if it is captured structurally, perhaps as part of workflow. The eCQM doesn't require EHRs implement patient refusal in workflow because each system and each provider have their preferences of workflow. The hospital would not receive negative score for not capturing patient refusal data, rather the hospital would not be able to improve their score because they couldn't utilize a second chance offered by the eCQM logic