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Documentation of Current Medications in the Medical Record

Last updated: May 9, 2019

CMS Measure ID: CMS68v9
Version: 9
NQF Number: 419e
Measure Description:

Percentage of visits for patients aged 18 years and older for which the eligible professionalinfo-icon or eligible clinicianinfo-icon 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 Population:

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

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

None

Numerator Statement:

Eligible professionalinfo-icon or eligible clinicianinfo-icon 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 (CMS)
Domain: Patient Safety
Previous Version:
Measure Scoring: Proportion
Measure Type: Process
Improvement Notation:

Higher score indicates better quality

Guidance:

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

Eligible professionalsinfo-icon or eligible cliniciansinfo-icon 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 professionalinfo-icon or eligible clinicianinfo-icon 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.

Quality ID: 130
Meaningful Measure: Medication Management

Specifications

Release Notes

Header

  • Updated eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Added 'e' to NQFinfo-icon number.

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale statement based on recent literature.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • ​Updated clinical recommendation statement to align with updated clinical guidelines.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Expert Work Group Review

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Medications Encounter Code Set (2.16.840.1.113883.3.600.1.1834): Deleted 2 SNOMED CT codes (30346009, 37894004).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code systeminfo-icon versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measureinfo-icon Logic and Implementation Guidance document for a list of code system versions used in the eCQM specificationsinfo-icon for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMsinfo-icon. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

External Resources