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Documentation of Current Medications in the Medical Record

Compare Versions of: "Documentation of Current Medications in the Medical Record"

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Measure Information 2022 Performance Period 2023 Performance Period 2024 Performance Period 2025 Performance Period
Title Documentation of Current Medications in the Medical Record Documentation of Current Medications in the Medical Record Documentation of Current Medications in the Medical Record Documentation of Current Medications in the Medical Record
CMS eCQM ID CMS68v11 CMS68v12 CMS68v13 CMS68v14
CBE ID* Not Applicable Not Applicable Not Applicable Not Applicable
MIPS Quality ID 130 130 130 130
Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Description

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

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

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

Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter

Measure Scoring Proportion measure Proportion measure Proportion measure Proportion measure
Measure Type Process Process Process Process
Stratification *See CMS68v11.html *See CMS68v12.html

None

None

Risk Adjustment *See CMS68v11.html *See CMS68v12.html

None

None

Rationale *See CMS68v11.html *See CMS68v12.html

According to the National Center for Health Statistics, during the years of 2013-2016, 48.4% of patients (both male and female) were prescribed at least one prescription medication with 12.6% taking 5 or more medications. Additionally, 89.8% of patients (both male and female) aged 65 years and older were prescribed at least one medication with 40.9% taking 5 or more medications (2018). In this context, maintaining an accurate and complete medication list has proven to be a challenging documentation endeavor for various health care provider settings. While most of outpatient encounters (two-thirds) result in providers prescribing at least one medication, hospitals have been the focus of medication safety efforts (Stock, Scott, & Gurtel, 2009). Nassaralla, Naessens, Chaudhry, Hansen, and Scheitel (2007) caution that this is at odds with the current trend, where patients with chronic illnesses are increasingly being treated in the outpatient setting and require careful monitoring of multiple medications. Additionally, Nassaralla et al. (2007) reveal that it is in fact in outpatient settings where more fatal adverse drug events (ADE) occur when these are compared to those occurring in hospitals (1 of 131 outpatient deaths compared to 1 in 854 inpatient deaths). In the outpatient setting, ADEs occur 25% of the time and over one-third of these are considered preventable (Tache, Sonnichsen, & Ashcroft, 2011). Particularly vulnerable are patients over 65 years, with evidence suggesting that the rate of ADEs per 10,000 person per year increases with age; 25-44 years old at 1.3; 45-64 at 2.2, and 65 + at 3.8 (Sarkar, López, Maselli, & Gonzales, 2011). Other vulnerable groups include individuals who are chronically ill or disabled (Nabhanizadeh, Oppewal, Boot, & Maes-Festen, 2019). These population groups are more likely to experience ADEs and subsequent hospitalization.

A multiplicity of providers and inadequate care coordination among them has been identified as barriers to collecting complete and reliable medication records. A study conducted by Poornima et al. (2015) indicates that reconciliation and documentation continue to be poorly executed with discrepancies occurring in 92% of patients (74 of 80) admitted to the emergency room. Of 80 patients included in the study, the home medications were reordered for 65% of patients on their admission. Of the 65%, 29% had a change in their dosing interval, while 23% had a change in their route of administration, and 13% had a change in dose. A total of 361 medication discrepancies, or the difference between the medications patients were taking before admission and those listed in their admission orders, were identified in at least 74 patients. The study found that "Through an appropriate reconciliation programme, around 80% of errors relating to medication and the potential harm caused by these errors could be reduced" (Poornima et al., 2015). Presley et al. (2020) also recognized specific barriers to sufficient medication documentation and reconciliation in rural and resource-limited care settings.

Documentation of current medications in the medical record facilitates the process of medication review and reconciliation by the provider, which is necessary for reducing ADEs and promoting medication safety. The need for provider to provider coordination regarding medication records, and the existing gap in implementation, is highlighted in the American Medical Association's Physician's Role in Medication Reconciliation, which states that "critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes" (2007). This is because clinical decisions based on information that is incomplete and/or inaccurate are likely to lead to medication error and ADEs. Weeks, Corbette, and Stream (2010) noted similar barriers and identified the utilization of health information technology as an opportunity for facilitating the creation of universal medication lists. One 2015 meta-analysis showed an association between electronic health record (EHR) documentation with an overall risk ratio (RR) of 0.46 (95% CI = 0.38 to 0.55; P < 0.001) and ADEs with an overall RR of 0.66 (95% CI = 0.44 to 0.99; P = 0.045). This meta-analysis provides evidence that the use of the EHR can improve the quality of healthcare delivered to patients by reducing medication errors and ADEs (Campanella et al., 2016).

According to the National Center for Health Statistics, during the years of 2013-2016, 48.4% of patients (both male and female) were prescribed at least one prescription medication with 12.6% taking 5 or more medications. Additionally, 89.8% of patients (both male and female) aged 65 years and older were prescribed at least one medication with 40.9% taking 5 or more medications (2018). In this context, maintaining an accurate and complete medication list has proven to be a challenging documentation endeavor for various health care provider settings. While most of outpatient encounters (two-thirds) result in providers prescribing at least one medication, hospitals have been the focus of medication safety efforts (Stock, Scott, & Gurtel, 2009). Nassaralla, Naessens, Chaudhry, Hansen, and Scheitel (2007) caution that this is at odds with the current trend, where patients with chronic illnesses are increasingly being treated in the outpatient setting and require careful monitoring of multiple medications. Additionally, Nassaralla et al. (2007) reveal that it is in fact in outpatient settings where more fatal adverse drug events (ADE) occur when these are compared to those occurring in hospitals (1 of 131 outpatient deaths compared to 1 in 854 inpatient deaths). In the outpatient setting, ADEs occur 25% of the time and over one-third of these are considered preventable (Tache, Sonnichsen, & Ashcroft, 2011). Particularly vulnerable are patients over 65 years, with evidence suggesting that the rate of ADEs per 10,000 person per year increases with age; 25-44 years old at 1.3; 45-64 at 2.2, and 65 + at 3.8 (Sarkar, López, Maselli, & Gonzales, 2011). Other vulnerable groups include individuals who are chronically ill or disabled (Nabhanizadeh, Oppewal, Boot, & Maes-Festen, 2019). These population groups are more likely to experience ADEs and subsequent hospitalization.

A multiplicity of providers and inadequate care coordination among them has been identified as barriers to collecting complete and reliable medication records. A study conducted by Poornima et al. (2015) indicates that reconciliation and documentation continue to be poorly executed with discrepancies occurring in 92% of patients (74 of 80) admitted to the emergency room. Of 80 patients included in the study, the home medications were reordered for 65% of patients on their admission. Of the 65%, 29% had a change in their dosing interval, while 23% had a change in their route of administration, and 13% had a change in dose. A total of 361 medication discrepancies, or the difference between the medications patients were taking before admission and those listed in their admission orders, were identified in at least 74 patients. The study found that "Through an appropriate reconciliation programme, around 80% of errors relating to medication and the potential harm caused by these errors could be reduced" (Poornima et al., 2015). Presley et al. (2020) also recognized specific barriers to sufficient medication documentation and reconciliation in rural and resource-limited care settings.

Documentation of current medications in the medical record facilitates the process of medication review and reconciliation by the provider, which is necessary for reducing ADEs and promoting medication safety. The need for provider to provider coordination regarding medication records, and the existing gap in implementation, is highlighted in the American Medical Association's Physician's Role in Medication Reconciliation, which states that "critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes" (2007). This is because clinical decisions based on information that is incomplete and/or inaccurate are likely to lead to medication error and ADEs. Weeks, Corbette, and Stream (2010) noted similar barriers and identified the utilization of health information technology as an opportunity for facilitating the creation of universal medication lists. One 2015 meta-analysis showed an association between electronic health record (EHR) documentation with an overall risk ratio (RR) of 0.46 (95% CI = 0.38 to 0.55; P < 0.001) and ADEs with an overall RR of 0.66 (95% CI = 0.44 to 0.99; P = 0.045). This meta-analysis provides evidence that the use of the EHR can improve the quality of healthcare delivered to patients by reducing medication errors and ADEs (Campanella et al., 2016).

Clinical Recommendation Statement *See CMS68v11.html *See CMS68v12.html

The Joint Commission's 2020 Ambulatory Health Care National Patient Safety Goals guide providers to maintain and communicate accurate patient medication information. Specifically, the section "Use Medicines Safely NPSG.03.06.01" states the following: “Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.”

The National Quality Forum's Safe Practices for Better Healthcare (2010), states the following: "the healthcare organization must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care."

The Joint Commission's 2023 Ambulatory Health Care National Patient Safety Goals guide clinicians to maintain and communicate accurate patient medication information (2023). Specifically, the section NPSG.03.06.01 "Maintain and communicate accurate patient medication information" states the following: "Obtain and/or update information on the medications the patient is currently taking. This information is documented in a list or other format that is useful to those who manage medication. Compare the medication information the patient brought to the organization with the medications ordered for the patient by the organization in order to identify and resolve discrepancies.”

The Joint Commission's 2023 Hospital National Patient Safety Goals also addressed documenting current medications (2023). Specifically, the section NPSG.03.06.01 "Maintain and communicate accurate patient information" states the following: "Obtain information on the medications the patient is currently taking when they are admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications."

The National Quality Forum's Safe Practices for Better Healthcare (2010), states the following: "The healthcare organization must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care."

Improvement Notation

Higher score indicates better quality

Higher score indicates better quality

Higher score indicates better quality

Higher score indicates better quality

Definition *See CMS68v11.html *See CMS68v12.html

Current Medications:

Medications the patient is presently taking including all prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, and cannabis/cannabidiol products with each medication's name, dosage, frequency and administered route.

Route:

Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).

Current Medications:

Medications the patient is presently taking including all prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, and cannabis/cannabidiol (CBD) products with each medication's name, dosage, frequency and administered route.

Route:

Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).

Guidance

This eCQM is an episode-based measure. An episode is defined as each eligible encounter during the measurement period. This measure is to be reported for every encounter during the measurement period.

Eligible professionals or eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources.

 

By reporting the action described in this measure, the provider attests to having documented a list of current medications utilizing all immediate resources available at the time of the encounter.

This list must include all known prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

This measure should also be reported if the eligible professional or eligible clinician documented the patient is not currently taking any medications.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

This eCQM is an episode-based measure. An episode is defined as each eligible encounter during the measurement period. This measure is to be reported for every encounter during the measurement period.

Eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources.

 

By reporting the action described in this measure, the provider attests to having documented a list of current medications utilizing all immediate resources available at the time of the encounter.

This list must include all known prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements, cannabis/cannabidiol products AND must contain the medications' name, dosage, frequency and route of administration.

This measure should also be reported if the eligible clinician documented the patient is not currently taking any medications.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This eCQM is an episode-based measure. An episode is defined as each eligible encounter during the measurement period. This measure is to be reported for every encounter during the measurement period.

Eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources.

 

By reporting the action described in this measure, the provider attests to having documented a list of current medications utilizing all immediate resources available at the time of the encounter.

This list must include all known prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, cannabis/cannabidiol products AND must contain the medications' name, dosage, frequency and route of administration.

This measure should also be reported if the eligible clinician documented the patient is not currently taking any medications.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This eCQM is an episode-based measure. An episode is defined as each eligible encounter during the measurement period. This measure is to be reported for every eligible encounter during the measurement period.

Eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources.

 

By reporting the action described in this measure, the provider attests to having documented a list of current medications utilizing all immediate resources available on the day of the encounter.

This list must include all known prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, cannabis/cannabidiol (CBD) products AND must contain the medications' name, dosage, frequency and route of administration.

This measure should also be reported if the eligible clinician documented the patient is not currently taking any medications.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Initial Population

All visits occurring during the 12-month measurement period for patients aged 18 years and older

All visits occurring during the 12-month measurement period for patients aged 18 years and older

All visits occurring during the 12-month measurement period for patients aged 18 years and older

All visits occurring during the 12-month measurement period

Denominator

Equals Initial Population

Equals Initial Population

Equals Initial Population

Equals Initial Population

Denominator Exclusions

None

None

None

None

Numerator

Eligible professional or eligible clinician attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter

Eligible clinician attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter

Eligible clinician attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter

Eligible clinician attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Denominator Exceptions

Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g., 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)

Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g., 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)

Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g., 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)

Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g., 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)

Telehealth Eligible Yes Yes Yes Yes
Next Version No Version Available
Previous Version No Version Available
Specifications
Attachment Size
CMS68v14.html 64.63 KB
CMS68v14.zip 60.44 KB
CMS68v14-TRN.xlsx 23.11 KB
eCQM Jira Issue Tracker
*Note there may be more tickets in the eCQM Tracker - ONC Project Tracking System (Jira) for this measure. Only tickets tagged with their associated CMS measure ID appear.

Header

  • Updated the eCQM version number.

    Measure Section:

    eCQM Version Number

    Source of Change:

    Annual Update

  • Changed all references from NQF to CBE to identify the consensus-based entity role.

    Measure Section:

    CBE Number

    Source of Change:

    Annual Update

  • Removed Denominator age requirement. Changed Initial Population age criteria from 18 and older to all ages based on expert input that medications should be documented or reviewed for patients of all ages.

    Measure Section:

    Description

    Source of Change:

    Expert Work Group Review

  • Updated copyright.

    Measure Section:

    Copyright

    Source of Change:

    Annual Update

  • Updated Guidance to reflect change in Numerator timing to allow for the attestation of medication review to be completed during the day of the encounter to allow for different clinical workflows.

    Measure Section:

    Guidance

    Source of Change:

    Measure Lead

  • Removed Denominator age requirement. Changed Initial Population age criteria from 18 and older to all ages based on expert input that medications should be documented or reviewed for patients of all ages.

    Measure Section:

    Initial Population

    Source of Change:

    Expert Work Group Review

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section:

    Multiple Sections

    Source of Change:

    Annual Update

  • Updated references and measure header to reflect current evidence and new or updated literature.

    Measure Section:

    Multiple Sections

    Source of Change:

    Measure Lead

Logic

  • Removed age requirement that patients be 18 years or older at the start of the measurement period. Changed Initial Population from 18 and older to all ages based on expert input that medications should be documented or reviewed for patients of all ages.

    Measure Section:

    Initial Population

    Source of Change:

    Expert Work Group Review

  • Updated Numerator timing to allow for the attestation of medication review to be completed during the day of the encounter to allow for different clinical workflows.

    Measure Section:

    Numerator

    Source of Change:

    Measure Lead

  • Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.

    Measure Section:

    Definitions

    Source of Change:

    Standards/Technical Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    Measure Section:

    Definitions

    Source of Change:

    Annual Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    Measure Section:

    Functions

    Source of Change:

    Annual Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Encounter to Document Medications (2.16.840.1.113883.3.600.1.1834): Added 1 CPT code (92622) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (99211) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.

    Measure Section:

    Terminology

    Source of Change:

    Annual Update

Last Updated: Jun 03, 2024