Clinical Quality Measure
CMS068v3 (NQF 0419) - Adult Recommended Core Measure

Documentation of Current Medications in the Medical Record

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.



NQS DOMAIN:   Patient Safety




Description and Implementation within the EMR software

Denominator: All visits occurring during reporting period for patients aged 18 years and older before the start of the measurement period.

Numerator: Patients in the above mentioned list whose current medication list was documented or updated or reviewed, including all known prescriptions, over-the-counters, herbals and nutritional supplements. UniCharts looks for the custom code QM419A: [Quality Measure] Current medication list documented or updated or reviewed during this encounter (G8427) within the PROCEDURES/SERVICES section on the ENCOUNTER form as the required documentation.

Exceptions: UniCharts looks for the custom code QM419E: [Exception] Action specified in CMS068v3 not performed due to medical, patient, or system reasons within the PROCEDURES/SERVICES section on the ENCOUNTER form as the required documentation.

NOTE: As the medication Favorite List on the encounter form also presents that patient`s master medication list for review, the EMR automatically inserts code QM419A within the PROCEDURES/SERVICES section if a prescription is found on that patient encounter.

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