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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.

Denominator Exclusion:    None


Denominator Exceptions: 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.
 

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.

 

Numerator Exclusions:     Not applicable

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.

 

Quality ID #130


Measure type: Process


High Priority Measure: Yes