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): Traditional Merit-based Incentive Payment System (MIPS)
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 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
No
Risk Adjustments

None

Stratifications

None

Collection and Reporting Attributes

Type of Data Collection
Administrative data, Electronic/paper chart records
Data Collection Methods

Merit-Based Incentive Payment System traditional reporting

Frequency of Data Collection
Annually
Frequency of Data Collection in Days
365
Reporting Methods

Merit-Based Incentive Payment System

Reporting Frequency
Annually
Reporting Frequency in Days
365
Indicator Has Recommended Targets
No

Source and Reference Attributes

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