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Exclusion: Any EP, eligible hospital or CAH for whom the total of transitions or referrals received and patient

encounters in which the provider has never before encountered the patient, is fewer than 100 during the HER

reporting period is excluded from this measure.

NOTE: There are changes to the measure calculations policy, which specifies that actions included the

numerator must occur within the EHR reporting period if that period is a full calendar year, or if it is less than a

full calendar year, within the calendar year in which the EHR reporting period occurs.

Summary of Care Documents

All summary of care documents used to meet this objective must include the information outlined in Table 1 (if

the provider knows it). In circumstances where there is no information available to populate one or more of the

fields listed, either because the provider can be excluded from recording such information or because there is

no information to record (e.g., laboratory tests), the provider may leave the field(s) blank and still meet the

objective and its associated measure.

Note: The current problem list, current medication list, and current medication allergy list may not be left

blank. These fields must include the most recent information known by the EP or eligible hospital as of the time

of generating the summary of care document, or include a notation of no current problem, medication and/or

medication allergies.

Table 1:

What to Include in Summary of Care Documents



Patient name

Care plan field, including goals and instructions



Referring or transitioning provider's name and

Care team, including the primary care provider of

office contact information (EP only)

record and any additional known care team



Procedures

members beyond the referring or transitioning



Encounter diagnosis

provider and the receiving provider.



Immunizations

Discharge instructions (Hospital Only)



Laboratory test results

Reason for referral (EP only)



Vital signs (height, weight, blood pressure,

BMI)

Summary of care documents must also include:*



Smoking status

Current problem list (providers may also include



Functional status, including activities of daily

historical problems at their discretion)



living, cognitive and disability status

Current medication list (a list of medications that a



Demographic information (preferred

patient is currently taking)



language, sex, race, ethnicity, date of birth)

Current medication allergy list (a list of medications

to which a given patient has known allergies)

* An EP or eligible hospital must verify these three 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 EP or

hospital as of the time of generating the summary of care document

Note about Lab Results: The final rule for Stage 3 requires a provider to have the ability to send all laboratory

test results in the summary of care document. However, the provider may work with their system developer to

establish clinically relevant parameters based on their specialty, patient population, or for certain transitions

and referrals that allow for clinical relevance to determine the most appropriate results for given transition or

Medicaid Ehr Incentive Program Health Information Exchange - Objective Stage 3 - Centers For Medicare And Medicaid Services Page 3

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