CMS 68 - Documentation of Current Medications in the Medical Record

Medical Codify

CMS68v6 (2017)

CMS68v7 (2018)

CMS68v8 (2019)

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:  Equals Initial Population

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

Inverse Measure:  No

Clinical Instructions

Review and update the medications in the Presenting Medications section of the encounter, as appropriate, including ALL current prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary supplements, with name(s), dosage(s), frequency, and route(s) of administration.

  • While documenting the Visit Encounter, open the Presenting Medications section of the encounter, and begin a review of all current medications.
  • Add, remove, and/or update the medications, as appropriate.
  • After reviewing and updating the medications, select the Medication reconciliation done box.
  • Continue documenting the encounter as appropriate.
  • When completed, Close and Archive the encounter

Evidence

Initial Patient Population

Name Value Set
Encounter, Performed: Medications Encounter Code Set 2.16.840.1.113883.3.600.1.1834

Denominator

Equals Initial Population

Numerator

Name Value Set
Procedure, Performed: Documentation of current medications (procedure) SNOMEDCT version 2017-09 Code 428191000124101

Denominator Exception

Name Value Set
Procedure, Not Performed: Documentation of current medications (procedure) 2.16.840.1.113883.3.600.1.1502

Source(s)

Medical Codify

WebChart Documentation
Last Build: Wed, 08 Sep 2021 00:25:59 EDT Legacy Documentation