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Documentation of Current Medications in the Medical Record

Updated: 10/22/2019
Views: 1967

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 occurring during the 12-month measurement period 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 clinician 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 needs to perform a Medication Reconciliation.  This should be completed at each visit.   
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 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.
Quality ID: 130
CMS Measure ID: CMS68
Measure type: Process
High Priority Measure: Yes