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Definition of Terms
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- Transition of Care – The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory, specialty care practice, long-term care, home health, rehabilitation facility) to another. At a minimum, this includes all transitions of care and referrals that are ordered by the MIPS eligible clinician.
- Summary of Care Record – All summary of care documents used to meet this measure must include the following information if the MIPS eligible clinician knows it:
- Patient name
- Referring or transitioning healthcare provider's name and office contact information (MIPS eligible clinician only)
- Procedures
- Encounter diagnosis
- Immunizations
- Laboratory test results
- Vital signs (height, weight, blood pressure, BMI)
- Smoking status
- Functional status, including activities of daily living, cognitive and disability status
- Demographic information (preferred language, sex, race, ethnicity, date of birth)
- Care plan field, including goals and instructions
- Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider
- Reason for referral (MIPS eligible clinician only)
- Current problem list (Providers may also include historical problems at their discretion)*
- Current medication list*
- Current medication allergy list*
*Note: A MIPS eligible clinician must verify that the fields for current problem list, current medication list, and current medication allergy list are not blank and include the most recent information known by the MIPS eligible clinician as of the time of generating the summary of care document or include a notation of no current problem, medication and/or medication allergies.
- Current problem lists – At a minimum, a list of current and active diagnoses.
- Active/current medication list – A list of medications that a given patient is currently taking.
- Active/current medication allergy list – A list of medications to which a given patient has known allergies.
- Allergy – An exaggerated immune response or reaction to substances that are generally not harmful.
- Care Plan – The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the MIPS eligible clinician has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).
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