Medical Records: Compliance with CMS Hospital CoPs and Proposed Changes

Product Id : HE121
Instructor : Sue Dill Calloway
Jun 21, 2019 12:00 PM ET | 11:00 AM CT | 09:00 AM PT | 90 Minutes

Description

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?

This program will cover in detail the CMS regulations and interpretive guidelines for medical records. This is an extremely important section and includes 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 2018 under the Hospital Improvement Rule, containing changes to outpatient medical records, the rights of patients and documentation changes. The speaker will also cover some information on HIPAA from the Office of Civil Rights and discuss the important proposed changes to the CMS discharge planning standards and the number of things that will need to be documented in the medical record.

This program will cover some information on HIPAA from the Office of Civil Rights including the difference between patient access verses when an authorization is needed. It will discuss the changes to the federal law on alcohol and drug records which are now called substance abuse disorder records under 42 CFR Part 2.

Learning Objectives:

  • Recall that CMS has specific informed consent requirements
  • Describe when a 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

Session Agenda:

  • 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
  • How to keep posted of new changes
  • Confidentiality and privacy memo
  • MOON form
  • IM and detailed notice forms
  • Transfer form requirements and proposed changes
  • Final changes to federal drug and alcohol drug 42 CFR Part 2
  • OCR information on HIPAA on patient access verses authorization
  • TJC changes to comply with CoPs
  • Autopsies
  • AHIMA practice guidelines
  • HITECH and Breech 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
    • Preanesthesia 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

Who Will Benefit:

  • Director of Health Information Management
  • Health Information Management staff
  • Chief Nursing Officer (CNO)
  • Compliance Officer
  • Director of Radiology
  • Lab Director
  • Hospital Legal Counsel
  • C-level Executives
  • Quality Improvement Coordinator
  • Patient Safety Officer
Speaker Profile:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.


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