MIPS Quality Measure ID #130, “Documentation of Current Medications in the Medical Record” carries extensive documentation requirements. Too many providers are under the impression that merely documenting the patient’s medication list satisfies the performance of this measure, and it does not. The use of the term “medications” in the measure title is misleading because much more than just documenting the patient’s medications is required to satisfy the requirements of this measure.
To perform this measure, the clinician must document that they “obtained, updated, or reviewed” a list that must include the name, dosage, frequency and route of administration of all “known prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, cannabis/cannabidiol products.”
That is a lot more than just a medication list!
In order to obtain this list, the measure requires the clinician to “make their best effort using all immediate resources available on the date of the encounter.” These “immediate resources” may include patient reporting, formulary access, pharmacy reports, information from the primary care provider, and more.
An example of documenting this measure is:
Today, I made my best effort using all immediate resources available to obtain the name, dosage, frequency, and route of administration of all of this patient’s known prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, and cannabis/cannabidiol products. I obtained this list by compiling what the patient reported to me and accessing the patient’s formulary that was available using the tools provided by my EHR. This list includes:
Then follow that by documenting:
- All the patient’s prescriptions and dosage, frequency, and route of administration for each
- All the patient’s over-the-counter products and dosage, frequency, and route of administration for each
- All the patient’s herbals and dosage, frequency, and route of administration for each
- All the patient’s vitamins and dosage, frequency, and route of administration for each
- All the patient’s minerals and dosage, frequency, and route of administration for each
- All the patient’s dietary (nutritional) supplements and dosage, frequency, and route of administration for each
- All the patient’s cannabis/cannabidiol products and dosage, frequency, and route of administration for each
