CMS68v11 – Documentation of Current Medications in the Medical Record

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

– DENOMINATOR EXCEPTION

Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list.

– 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.

For Denominator:

All patients aged 18 years and older at the start of the measurement period and with a qualifying encounter during the measurement period, are included in the denominator. To record an encounter, navigate to Patient > Provider Note > eSuperbill.

For Numerator:

Include all patients with a documentation of the current medications during the qualifying encounter.

• To record medication, navigate to Patient > Provider Note > Medications. Click ‘Add’ and search for the medication. Complete the medication details and click ‘Save’. Then click ‘Accept’ and the medication is added to the provider note.

Note: The documentation must include all known prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.

• To document the intervention performed during an encounter, use the workflow Patient > Clinical > Evaluations. Click ‘+ Evaluation’ and search for an intervention. From the ‘Status’ dropdown, select ‘Performed’, then click ‘Sign’ or ‘Save.

For Denominator Exception:

Patients with a documentation of a medical reason for not documenting, updating, or reviewing the patient’s current medications list are included in denominator exceptions. The medical reason must be recorded during the qualifying encounter.

• Navigate to Patient > Provider Note > Medications and click on ‘Add’. Mark the ‘Patient refused to provide current medication details’ checkbox.

• To record the documentation intervention as not performed, use the workflow Patient > Clinical > Evaluations. Click ‘+ Evaluation’ and search for ‘Documentation of current medications (procedure)’ intervention. From the ‘Status’ dropdown, select ‘Not Performed’ and from the ‘Reason’ drop-down, select a reason. Then click ‘Sign’ or ‘Save.