CMS68v13 – Documentation of Current Medications in the Medical Record

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

– NUMERATOR

Eligible clinician attests to documenting, updating, or reviewing the patient’s current medications using all immediate resources available on the date of the encounter.

– DENOMINATOR EXCEPTION

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

For Denominator:

To record an encounter, navigate to Patient > Provider Note > Create Superbill. Under the ‘Procedures-CPT’ heading, enter the relevant encounter code.

For Numerator:

• 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’ for the medication to be 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 > Provider Note > Evaluations. Click ‘Add’ and search for the relevant intervention. From the ‘Status’ dropdown, select ‘Performed’ and then click ‘Save & Accept’ or ‘Sign & Accept’.

For Denominator Exceptions:

• To record medical reasons for not documenting current medication intervention, head over to Patient > Provider Note > Evaluations. Here, click ‘Add’ and search for ‘Documentation of Current Medication (Procedure)’. From the ‘Status’ drop-down select ‘Not Performed’ and from the ‘Reason’ drop-down select the relevant reason.
• Additionally, the documentation of reasons for not prescribing medication can be done via Patient > Provider Notes > Medications > Current > Discontinue. Here, the reason for discontinuing an active medication is to be selected from the drop-down.