Documentation of Current Medications in the Medical Record*

eCQM / NQF #: CMS68v8 / 0419
Measure: 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.
Numerator: 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.
Denominator: All visits occurring during the 12 month measurement period for patients aged 18 years and older.
Denominator Exception: 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
Exclusion: None
Domain: Patient Safety

In ChartMaker Clinical:

In order to qualify for this measure, the provider must have seen the patient (age 18 and older) at least one time during the reporting period and have the appropriate information documented in the chart:

Required Data Elements for the Denominator:

Required Data Element for the Numerator:

EXCEPTION DETAILS:

There is no exclusion for this measure.  However, there is a denominator exception when a 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.  In order to meet the requirements for this exception, the appropriate information must be documented in the chart:

ADDITIONAL INFORMATION:

• This measure is to be reported for every encounter during the measurement period. This measure is not based on unique patients, therefore if a patient meeting the measure criteria was seen more than once during the reporting period, that patient would be counted in the numerator/denominator more than once.

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

• This measure should also be reported if the eligible professional documented the patient is not currently taking any medications.

•  To meet the numerator, the 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. Route of administration should be documented on how the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).

•   The "Current Medications Documented" choice is defaulted to being checked.  If you can not attest to the information in the bullet point above, it should be unchecked.

•  When "Current Medications Documented" is unchecked, the system will automatically apply a reason code for the procedure not done (Medical Reason).

• The only data used to determine the denominator is data from the ChartMaker Clinical Module. If a patient encounter was not entered into the ChartMaker Clinical Module, that encounter is not included in the denominator for the statistical calculations on the Meaningful Use Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.