Here are a few quick documentation tips that will help you meet the quality measure requirements in 
2018:
Depression Screening
Our Depression Screening score for Medicare annual reporting improved significantly in 2017. Let’s keep that momentum going! Here are just a few reminders.
- Please continue to perform depression screenings on follow-up visits as well as AWV visits. This ensures that patients who refuse to get AWV’s will still be screened for depression.
- Please remember to mention the depression screening in your assessment and plan. If the screening is negative simply stating the depression screening is negative is acceptable. If the screening is positive please document a follow-up plan.
Tobacco Screening
This quality measure is asking that tobacco use be addressed, not just whether or not a patient smokes.
Athena Users: Recent audits indicate that often only the smoking questions are being asked/answered, which is not going to satisfy this quality measure. Please remember to address the tobacco and other nicotine products question as well. If chewing tobacco is being used, then please address tobacco cessation with these patients.
Medication Reconciliation
Medication Reconciliation is required at all follow-up visits (PCP and specialty provider) within 30 days of hospital or skilled nursing facility discharge.
In 2017, CMS changed the measure so that it now requires reconciliation of the current medication list with the hospital or skilled nursing facility discharge list.
To satisfy this measure, the following phrase must be included in your documentation:
“Current medications were reconciled with the discharge medication list.”
This statement can be entered by nurse; by signing the note the provider attests to the reconciliation.