Home Quality Indicator Repository Documentation of Current Medications in the Medical Record

Documentation of Current Medications in the Medical Record

Identifying Attributes

Care Settings
Primary Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Physician Quality Reporting System (PQRS), Centers for Medicare & Medicaid Services (CMS): Medicare Shared Savings Program (MSSP), Centers for Medicare & Medicaid Services (CMS): Merit-Based Incentive Payment System (MIPS), Centers for Medicare & Medicaid Services (CMS): Physician Feedback/Quality and Resource Use Reports (QRUR), Centers for Medicare & Medicaid Services (CMS): Physician Value-Based Payment Modifier (VBM)
Type of Quality Indicator
Process
IOM Quality Dimension
Safety
Domain
Medications and Medication Management

Defining Attributes

Definition

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.

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 prescriptions, over-the counters, herbals, vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency, and route of administration.

Denominator

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

Exclusions

Medical Reason: Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardise the patient's health status

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

None

Collection and Reporting Attributes

Type of Data Collection
Administrative data, Standardised clinical data
Data Collection Methods

Reporting is specific to sub-program

Frequency of Data Collection
Frequency of Data Collection in Days
Reporting Methods
Reporting Frequency
Reporting Frequency in Days
Indicator Has Recommended Targets
No

Source and Reference Attributes

Evidence Source

p4qm.org/measures

Technical Specifications

p4qm.org/measures/0419e

Link to Measurement Tools
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
Yes
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
02 December 2025

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Date Modified 02 December 2025