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Kareo Help Center

Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter.  This list must include ALL known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.

 

Denominator:    All visits for patients aged 18 years and older.

  • Patient’s age is calculated based on the patient’s Date of Birth, which is entered when you created the patient’s account.

 

Numerator:  Eligible professional attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of the encounter.  This list must include ALL known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.

  • When reviewing a patient’s medication, clinical staff or providers need to place a checkmark in the Medication Reconciliation Performed box.  This should be completed at each visit.  See Document a Medication Reconciliation – Without Meaningful Use Reporting.

 

Numerator Exclusions:

  • If the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status, an exclusion will need to be documented on the Exclusion Section.  See How to document an exclusion.

 

Office Visit Documentation:

  • Create a Note detailing the patient’s office visit.  See Create a Note.
  • Make sure to include an E&M code under “Procedure Codes” on the Superbill.  See Create a Superbill.
  • Sign the Note.  See Sign Notes.  Once the note is signed, the measure will be added to the Quality Report.