Documentation of Current Medications in the Medical Record

Last updated: July 12, 2017

CMS Measure ID: CMS68v5
Version: 5
NQF Number: 0419
Measure Description:

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.

Initial Patient Population:

All visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

None

Numerator Statement:

Eligible professional attests to documenting, updating or reviewing the 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, dosages, frequency and route of administration

Numerator Exclusions:

Not Applicable

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

Measure Steward: Centers for Medicare & Medicaid Services
Domain: Patient Safety
Next Version: Documentation of Current Medications in the Medical Record
Previous Version: Documentation of Current Medications in the Medical Record
Measure Score: Proportion
Improvement Notation:

Higher score indicates better quality.

Guidance:

This measure is to be reported for every encounter during the measurement period.

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

This list must include all 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 documented the patient is not currently taking any medications.

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.

Specifications

Release Notes

Header

  • Clinical Recommendation Statement updated.
  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • Rationale updated.
  • Reference updated.

Logic

  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

  • Value set Medical or Other reason not done (OID 2.16.840.1.113883.3.600.1.1502): Added code 428119001.
  • Value set Medications Encounter Code Set (OID 2.16.840.1.113883.3.600.1.1834): Added 6 CPT codes (99385, 99386, 99387, 99395, 99396, 99397) and deleted 2 CPT codes (97110, 97140).

External Resources