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.
ACP does not support QPP measure 130: "Documentation of Current Medications in the Medical Record." While this measure represents an important clinical concept, there is a lack of high-quality evidence to support its inclusion in accountability programs, it is burdensome for clinicians to document complete medication lists at every patient visit, and encouraging documentation at every visit could result in underuse of more valuable clinical services. Additionally, interventions intended to improve the medication reconciliation process have not necessarily resulted in improved quality outcomes. Furthermore, this is a "check the box" measure. Attestation for these visits may become routine but does not add value. A more appropriate measure may encourage documentation of medication lists according to clinical necessity and incentivize a standardized, methodological approach to reconciliation, according to clinician practice level (e.g., physician, nurse, medical assistant) that leads to improvements in the medication management process. Furthermore, independent patient, system, and practice variables (incomplete patient information, unavailable drug information, miscommunication of drug orders, and insufficient information flow) can impede the physician’s ability to document complete an accurate medication lists. Consequently, clinical judgements may be based on incomplete clinical information.