What type of documentation is required for non-percentage-based measures?

  • MU-EP-Stage 1-Audits
  • MU-EP-Stage 2-Audits

To validate EP attestation for these objectives, CMS and its contractor may request additional supporting documentation.

A few examples of suggested documentation are listed:

  • Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support: One or more screenshots from the certified EHR system that demonstrate the enabling of the interventions during the EHR reporting period selected for attestation.
  • Report clinical quality measures: Report from the certified EHR system to validate all clinical quality measure data entered during attestation.
  • Protect Electronic Health Information: Documentation of security risk analysis of the certified EHR technology was performed prior to the end of the reporting period. 
  • Drug Formulary Checks: One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
  • Generate Lists of Patients by Specific Conditions: Report from the certified EHR system that is dated during the EHR reporting period selected for attestation. Patient-identifiable information may be masked/blurred before submission.
  • Immunization Registries Data Submission, Reportable Lab Results to Public Health Agencies, and Syndromic Surveillance Data Submission :
  • Dated screenshots from the EHR system that document a test submission to the registry or public health agency (successful or unsuccessful). Should include evidence to support that it was generated for that EP’s system.
    • A dated record of successful or unsuccessful electronic transmission (e.g, screenshot from another system, etc.). Should include evidence to support that it was generated for that provider.
    • Letter or email from registry or public health agency confirming the receipt (or failure of receipt) of the submitted data, including the date of the submission, name of parties involved, and whether the test was successful.
  • Exclusions - Documentation to support each exclusion to a measure claimed by the EP.