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 | 2023 Performance Period | 2024 Performance Period | 2025 Performance Period | 2026 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 | CMS68v12 | CMS68v13 | CMS68v14 | CMS68v15 |
| 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 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 |
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 CMS68v12.html |
None |
None |
None |
| Risk Adjustment | *See CMS68v12.html |
None |
None |
None |
| Rationale | *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). Show more >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). Show less |
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). Show more >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). Show less |
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). Show more >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). Show less |
| Clinical Recommendation Statement | *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." Show more >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." Show less |
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." Show more >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." Show less |
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." Show more >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." Show less |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Definition | *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). Show more >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). Show less |
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). Show more >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). Show less |
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. Encounter to Document Medications: An encounter performed during the measurement period where medications should be reviewed. 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). Show more >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. Encounter to Document Medications: An encounter performed during the measurement period where medications should be reviewed. 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). Show less |
| 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 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. Show more >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. Show less |
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. Show more >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. Show less |
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. Show more >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. Show less |
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. Show more >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. Show less |
| 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 |
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 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 |
None |
| 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) ... Show more >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) Show less |
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) ... Show more >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) Show less |
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) ... Show more >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) Show less |
Documentation of an acute health crisis where time is of the essence and delay of treatment would jeopardize the patient's health status |
| Telehealth Eligible | Yes | Yes | Yes | Yes |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Additional Resources for CMS68v15
*Note there may be more tickets for CMS68v15 in the eCQM Tracker - ASTP/ONC Project Tracking System (Jira). Only tickets tagged with their associated CMS measure ID appear.
Use the eCQM Tracker to open new issues regarding eCQM implementation. Log in required.
Header
TRN | Measure Section | Source of Change |
|---|---|---|
Changed the 'eCQM Identifier (Measure Authoring Tool)' field name to 'CMS ID' based on tooling updates. | CMS ID | Standards/Technical Update |
Updated the eCQM version number. | eCQM Version Number | Annual Update |
Updated the generic measurement period from 'January 1, 20XX through December 31, 20XX' to specify 'January 1, 2026 through December 31, 2026' based on tooling updates. | Measurement Period | Standards/Technical Update |
Revised Measure Developer to 'American Institutes for Research.' | Measure Developer | Annual Update |
Updated copyright. | Copyright | Annual Update |
Updated definition to add information on encounters to document medications to clarify the inclusion criteria. | Definition | Measure Lead |
Changed 'Numerator Exclusions' field to read 'None' instead of 'Not Applicable' when no exclusions are present. | Numerator Exclusions | Standards/Technical Update |
Updated 'Denominator Exceptions' statement to align with terminology update. | Denominator Exceptions | Annual Update |
Logic
TRN | Measure Section | Source of Change |
|---|---|---|
Updated Measure Primary CQL Library Name from 'DocumentationofCurrentMedications' to 'CMS68DocumentationOfCurrentMedicationsQDM' for alignment with the CQL Style Guide. | Definitions | Standards/Technical Update |
Updated the version number of the Global Common Functions Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM.' | Definitions | Annual Update |
Updated Numerator CQL logic to replace Global."NormalizeInterval" function with Global."EarliestOf" to better capture intent of attestation timing in representation of 'Medications Documented.' | Definitions | Annual Update |
Updated Numerator CQL logic to include Global."HasEnd" function so that the qualifying procedure must be completed to meet the numerator criteria. | Definitions | Annual Update |
Updated the timing comparison precision in the definitions by adding 'day of' operator to align with the measure intent and address time zone differences. | Definitions | Measure Lead |
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide. | Definitions | Standards/Technical Update |
Updated Measure Primary CQL Library Name from 'DocumentationofCurrentMedications' to 'CMS68DocumentationOfCurrentMedicationsQDM' for alignment with the CQL Style Guide. | Functions | Standards/Technical Update |
Updated the version number of the Global Common Functions Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM.' | Functions | Annual Update |
Updated Numerator CQL logic to replace Global."NormalizeInterval" function with Global."EarliestOf" to better capture intent of attestation timing in representation of 'Medications Documented.' | Functions | Annual Update |
Updated Numerator CQL logic to include Global."HasEnd" function to require end date of procedures or interventions documented using relevantPeriod. | Functions | 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.
TRN | Measure Section | Source of Change |
|---|---|---|
Value Set 'Encounter to Document Medications' (2.16.840.1.113883.3.600.1.1834): Added 23 CPT codes (98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99385, 99386, 99387, 99395, 99396, 99397) to align with CQM. | Terminology | Annual Update |
Replaced Value Set 'Medical Reason' (2.16.840.1.113883.3.526.3.1007) with Direct Reference Code SNOMEDCT 705016005: 'Acute health crisis (finding)' to constrain Denominator Exceptions. | Terminology | Annual Update |
Replaced Value Set 'ONC Administrative Sex' (2.16.840.1.113762.1.4.1) with Value Set 'Federal Administrative Sex' (2.16.840.1.113762.1.4.1021.121) to represent Supplemental Data Element 'SDE Sex' based on revised standards. | Terminology | Standards/Technical Update |