CMS 68 - Documentation of Current Medications in the Medical Record

Overview

CMS68v9 (2020)
CMS68v10 (2021)
CMS68v11 (2022)

Identifiers

CMS eCQM IDNQF eCQM IDNQFMIPS Quality ID
CMS68v11130
*MIE only supports data collection and reporting using eCQM specifications

Definitions

DescriptionPercentage of visits for patients aged 18 years and older for which the eligible professional or attests to documenting a list of current medications using all immediate resources available on the date of the encounter
Initial Patient PopulationAll visits occurring during the 12-month measurement period for patients aged 18 years and older
DenominatorEquals Initial Population
Denominator Exclusions
NumeratorEligible professional or attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter
Numerator Exclusions
Denominator ExceptionsDocumentation 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)

Additional Information

Measure TypeProcess Measure
Measure ScoringProportion measure
GranularityEncounter
Improvement NotationHigher score indicates better quality
DomainPatient Safety

Clinical Instructions

Ensure the list of current medications is always up-to-date for all patients.

Preferred Workflow

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.

If the Presenting Medications section is part of the encounter outline at time of archive and close, the appropriate SNOMED Concept ID will be documented for the encounter to achieve numerator credit.

Evidence

Initial Patient Population

NameValue Set
Encounter, Performed: Encounter to Document Medications2.16.840.1.113883.3.600.1.1834

Numerator

NameValue Set
Intervention, Performed: Documentation of current medications (procedure)SNOMEDCT Code 428191000124101
Procedure, Performed: Documentation of current medications (procedure)SNOMEDCT Code 428191000124101

Source(s)

eCQI CMS68


WebChart Documentation

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