Documentation of Current Medications in the Medical Record
Identifying Attributes
Care Settings
Country
Publishing Organisation
Type of Quality Indicator
IOM Quality Dimension
Domain
Defining Attributes
Definition
Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
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
All visits occurring during the 12-month measurement period for patients aged 18 years and older.
Exclusions
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 jeopardise the patient's health status).
Use of Risk Adjustment
Risk Adjustments
None
Stratifications
None
Collection and Reporting Attributes
Type of Data Collection
Data Collection Methods
Merit-Based Incentive Payment System traditional reporting
Frequency of Data Collection
Frequency of Data Collection in Days
Reporting Methods
Merit-Based Incentive Payment System