Documentation of Current Medications in the Medical Record

Last updated: October 25, 2017

CMS Measure ID: CMS68v7
Version: 7
NQF Number: 0419
Measure 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. 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 measurement period for patients aged 18 years and older.

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

None

Numerator Statement:

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. 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 and Medicaid Services (CMS)
Domain: Patient Safety
Previous Version: Documentation of Current Medications in the Medical Record
Improvement Notation:

Higher score indicates better quality

Guidance:

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.

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 or eligible clinician 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.

Addendum Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Modified Measure Developer name from 'Quality Insights of Pennsylvania' to 'Quality Insights.'.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • Updated Description.

    Measure Section: Description

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​​Updated Rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated References.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated Guidance.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Replaced the term 'reporting period' with 'measurement period' for consistency in terminology in the Initial Population language.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated Numerator.

    Measure Section: Numerator

    Source of Change: Measure Lead

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 Medications Encounter Code Set (2.16.840.1.113883.3.600.1.1834): Added 13 CPT codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Medications Encounter Code Set (2.16.840.1.113883.3.600.1.1834): Added 8 CPT codes (97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168) and deleted 4 CPT codes (97001, 97002, 97003, 97004).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources