Documentation of Current Medications in the Medical Record

Documentation of Current Medications in the Medical Record

To get credit for the High Priority Measure Documentation of Current Medications in the Medical Record you will need to document all over-the-counter and prescribed medications (prescribed by you or any prescriber) that the patient is taking AND use at least one of these service codes:

59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97127, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99236, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385, 99386, 99387, 99395, 99396, 99397, 99495, 99496

The Medication Reconciliation needs to be performed during referrals or transitions.

1. Go to the Medication Reconciliation button in the Complete Evaluation.

Screenshot for Documentation of Current Medications in the Medical Record

2. You will be brought to the Reconciliation Form first visit RX tab. Follow the instructions provided in the How To Use Medication Reconciliation (for medications) Knowledge Base Article for information on how to enter over-the-counter medications and external-Rx medications.

  a. Click the box for Complete Eval is from Referral / Transition

  b. Data entered = MU Credit - enter date

Screenshot for Documentation of Current Medications in the Medical Record

  c. Click the Confirm button

3. Once you return to the Progress Note:

  a. After you have confirmed the Medication Reconciliation  

  b. The Medication Reconciliation medicines will show under Medications. Add any medications that you will be prescribing. 

Screenshot for Documentation of Current Medications in the Medical Record

Screenshot for Documentation of Current Medications in the Medical Record

Screenshot for Documentation of Current Medications in the Medical Record

Screenshot for Documentation of Current Medications in the Medical Record

  c. Use a service code from one of the qualifying codes listed above. 

  d. Click the Compile this Note button.

4. When you get to the Finished Note screen, click the CQM Profile button. 

5. Go to the Documentation of Current Medications in the Medical Record and check if the Rx Medications Review was done or choose the reason from a drop-down menu why an RX was not done. 

Example of the drop-down menu.

    • Related Articles

    • Specify What Medical Record(s) Can Be Seen By Patient

      The ability to specify what medical records can be seen by the patient is done through the Upload Site by Group Administrators and Security Administrators. Only PDF and XML files can be set to be seen by the patient. This will be useful if you want ...
    • Preparing to Separate Your Current Practice into Two Separate Practices

      Index Sections Preparing to separate your current practice into two separate practices Considerations for awareness Actions required of the parties Preparing to separate your current practice into two separate practices Considerations for awareness ...
    • Processing Record Requests

      Index Sections Set Up How Patients Can Request Records Processing Record Requests The Patient Portal has been activated for your practice. Each patient will need to be invited to the Patient Portal and register their account to be able to request ...
    • How To Use Medication Reconciliation (for medications)

      The purpose of this knowledge base article is to guide users on how to utilize the Medication Reconciliation section of ICANotes to accurately document all medications a patient is currently taking at the time of admission or during their initial ...
    • Medication Administration Record (MAR) Training

      Medication Administration Record (MAR) Training The MAR training videos are a series of short videos designed to be viewed in sequence if you are not familiar with this workflow in ICANotes. For quick reference, each video may also be viewed ...