Document Current Medications

The Medication button menu has two options to indicate whether or not the patient's current medications have been documented: Current Medications Documented, and Current Medications Not Documented For Medical/Other Reason.

When the Current Medications Documented option is selected, this option will become checked and appear in boldface, and the Current Medications Not Documented For Medical/Other Reason option will become unchecked and appear in normal font. The system will record the applicable SNOMED code for selecting the Current Medications Documented option, and the CQM NQF0419 Documentation of Current Medications in the Medical Record query will be updated to accurate calculate this measure. Likewise, when each subsequent new note is created for the patient, this options will carry forward and remain checked until it is unchecked or the Current Medications Not Documented For Medical/Other Reason option is selected.

When the Current Medications Not Documented For Medical/Other Reason option is selected, this option will become checked and appear in boldface, and the Current Medications Documented option will become unchecked and appear in normal font. The system will record the applicable SNOMED code for selecting the Current Medications Not Documented For Medical/Other Reason option, and the CQM NQF0419 Documentation of Current Medications in the Medical Record query will be updated to accurate calculate this measure. Additionally, when the Current Medications Not Documented For Medical/Other Reason option is checked, this information will be outputted in the note. Also, do note that this option does not carry forward for subsequent patient notes, therefore, after the Current Medications Not Documented For Medical/Other Reason option is selected in the current note, in next note for the patient, both these options will be unchecked and you will need to manually select (activate) either of the two options as applicable.

Use the following steps to configure whether or not the current medications were documented during the patient's visit.

1. In the patient's chart note, click the Medication button.
    

2. Check the Current Medication Documented or the Current Medications Not Documented For Medical/Other Reason option, as needed.
   
   
   
    

3. The patient's note will updated and the applicable SNOMED codes will be recorded accordingly. If the Current Medications Not Documented For Medical/Other Reason option was selected this information will be outputted in the note.