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CMS 68 - Documentation of Current Medications in the Medical Record

Updated: 08/23/2021
Views: 2502

CMS 68 / Quality ID #130

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.

Denominator:  All visits occurring during the 12-month measurement period for patients aged 18 years and older at the start of the measurement period.
  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
Numerator: Eligible professional or eligible clinician attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of the encounter.
  • When reviewing a patient’s medication, clinical staff or providers must select "Performed" from the Medication Reconciliation drop-down. This should be completed at the time it was reviewed with the patient, which should match the date of service.
Denominator Exceptions: Medical reason: 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.
Office Visit Documentation:

Once all steps have been completed, the measure will be added to the Quality Measures Report.

Guidance: The measure is to be reported for every encounter during the measurement period. This measure should also be reported if the eligible clinician documented the patient is not currently taking any medications.
Measure type: Process
High Priority Measure: Yes
Telehealth Eligible: Yes