Documentation of Current Medications in the Medical Record

Last updated: June 9, 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 & 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.

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

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

    Section: Measure Developer

    Source: Measure Lead

  • Updated Description.

    Section: Description

    Source: Measure Lead

  • ​Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • ​​Updated Rationale.

    Section: Rationale

    Source: Measure Lead

  • Updated References.

    Section: Reference

    Source: Measure Lead

  • Updated Guidance.

    Section: Guidance

    Source: Measure Lead

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

    Section: Initial Population

    Source: Measure Lead

  • Updated Numerator.

    Section: Numerator

    Source: 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.

    Section: None

    Source: None

External Resources