Documentation of Current Medications in the Medical Record

Last updated: June 9, 2017

CMS Measure ID: CMS68v6
Version: 6
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 (CMS)
Domain: Patient Safety
Next Version: Documentation of Current Medications in the Medical Record
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 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.

Quality ID: 130
High Priority Measure: Yes
Data Submission Method: Claims,EHR,Registry
Specialty Measure Set: Allergy/Immunology,Internal Medicine,Anesthesiology,Cardiology,Dermatology,Emergency Medicine,Gastroenterology,General Surgery,General Oncology,Hospitalists,Neurology,Obstetrics/Gynecology,Ophthalmology,Orthopedic Surgery,Otolaryngology,Physical Medicine,Preventive Medicine,Rheumatology,Thoracic Surgery,Urology,Vascular Surgery,Mental/Behavioral Health,Plastic Surgery,General Practice/Family Medicine

Specifications

Release Notes

Header

  • Updated Clinical Recommendation Statement.

    Section: Clinical Recommendation Statement

    Source: Measure Lead

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Annual Update

  • Added Measure Item Count entry to indicate data element counted for an episode of care.

    Section: Measure Item Count

    Source: External Review

  • Revised rationale to provide succinct review of information.

    Section: Rationale

    Source: Measure Lead

  • Updated References.

    Section: Reference

    Source: Measure Lead

Value Set

  • Value set Medications Encounter Code Set (2.16.840.1.113883.3.600.1.1834): Deleted 3 SNOMEDCT codes (278465006, 397745006, 428119001). Added 4 CPT codes (92537, 92538, 92540, 92550) and deleted 8 CPT codes (90957, 90958, 90959, 90960, 90962, 90965, 90966, 92543).

    Section: None

    Source: None

External Resources