Documentation of Current Medications in the Medical Record
MIPS High Priority Measure:
Eligible for Quality Programs:
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.
- Numerator: Eligible visits from the denominator where the 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 eligible visits (defined as a signed chart note with one of the following encounter types: Office Visit or Home Visit) occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period.
Denominator Exclusions: None
Denominator Exceptions: 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.
Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to ensure that you gain numerator credit for this measure within the Practice Fusion EHR.
- For all visits with patients age 18 and older, review the patient’s medication list and ensure that it is up to date and complete.
- In the patient encounter, check the “Documentation of Current Medications” check-box in the Quality of Care section.
- Use Step 2 to record that the patient’s current medication list has been documented in the chart at every eligible encounter during the measurement period.
Additional Measure Information
- CMS defines “current medications” as medications the patient is presently taking, including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication's name, dosage, frequency and administered route.
- CMS defines “route” as the documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).
- 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 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.
- For the CMS specifications for this measure, please click here.
- To learn more about MIPS quality measure reporting requirements for 2017, visit What are the Quality measure reporting requirements for MIPS?
- For additional information about quality measures, you may also visit the CMS Quality Payment Programs website and Practice Fusion’s Quality Payment Program Center.