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Medical Records: Compliance with CMS Hospital CoPs and Proposed Changes

Recorded Session | Sue Dill Calloway | From: Oct 15, 2020 - To: Dec 31, 2020
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Course Description

This training program will cover in detail the CMS regulations and interpretive guidelines for medical records. It will also discuss important proposed changes to the CMS discharge planning standards including changes to the federal law on alcohol and drug records.

Areas Covered in the Webinar:-

  • Introduction to the CMS hospital CoPs
  • How to obtain a copy
  • CMS survey memos
  • Interpretive guidelines issued
    • Changes to verbal orders, standing orders, and H&P update
  • Proposed changes to CMS discharge planning standards and what forms would need to be changed
    • Five requirements for discharge instructions
    • Changes to transfer form, admission assessment form and discharge planning form
  • How to keep posted of new changes
  • Confidentiality and privacy memo
  • Proposed changes to federal drug and alcohol drug
  • OCR new information on HIPAA
  • TJC changes to comply with CoPs
  • Autopsies
  • AHIMA practice guidelines
  • HITECH and Breach Notification law
  • Final changes to privacy, security, HITECH
  • Verbal orders and changes
  • History and physicals
  • Grievances
  • Incident reports
  • Medical record service requirements
  • Medical record education and personnel
  • Author identification
  • Content of records
  • Standing orders and protocols
  • Legibility and authentication requirements
  • Informed consent
  • List of procedures for consent requirements
  • Discharge summaries
  • Completed medical records
  • Other sections of CoPs that are important for documentation in the medical record
    • Restraint and seclusion
    • Medication documentation
    • Pre-anesthesia assessment
    • Post-anesthesia assessment
    • Visitation with changes to advance directives, consent, and plan of care
    • Notification of OPO in deaths
    • Organ donation documentation
    • Anesthesia standards

Learning Objectives:-

  • Recall that CMS has specific informed consent requirements
  • Describe when history and physical must be done and what is required by CMS and the Joint Commission
  • Discuss that both CMS and TJS have standards on verbal orders
  • Recall that CMS has standards for preprinted orders, standing orders, and protocols.

Why Should You Attend:-

If a CMS surveyor showed up at your door tomorrow would you know what to do? Are you up to date on all the recent CMS hospital CoP changes? Did you know that all the medical records standards (health information management) apply to all departments including lab and x-ray?

Medical records are an extremely important section and include hot issues like verbal orders, history and physicals, organization of the department, standing orders, discharge summaries, medication orders, and more. It will include the proposed changes in 2017 under the Hospital Improvement Act. This includes changes to outpatient medical records, the rights of patients, and documentation changes. One proposed change would require that the diagnosis and records be completed within 7 days for outpatients.

The proposed changes to the discharge planning standards, along with a federal law known as the IMPACT Act, would include revision of the transfer form, discharge planning evaluation form, nursing admission assessment form, and would include five requirements for the discharge instructions. The discharge summary would need to be done and in the hands of the PCP within 48 hours. A discussion of the new Notice law or Moon form will be covered which requires a form to all observation patients.

CMS publishes a list of deficiencies received by hospitals and this will be discussed.

Who Will Benefit:-

  • Health Information Management Director
  • Health Information Management Staff
  • Chief Nursing Officer (CNO)
  • Compliance Officer
  • Radiology Director
  • Lab Director
  • Hospital Legal Counsel
  • Chief Executive Officer (CEO)
  • Chief Operating Officer (COO)
  • Chief Medical Officer (CMO)
  • Joint Commission Coordinator
  • Quality Improvement Coordinator
  • Risk Managers
  • Nurse Educator
  • Patient Safety Officer
  • Emergency Department Manager
  • Nurse Managers/Supervisors
  • Staff Nurses
  • Clinic Managers
  • Medical Department Nurse Manager
  • Surgery Department Nurse Manager
  • OR Nurse Director
  • ICU Nurse Director
  • CCU Nurse Director
  • Outpatient Director
  • IS Director
  • Policy and Procedure Committee
  • Anyone involved in the implementation of the CMS or Joint Commission medical record and documentation standards