Medical Records: Compliance with CMS Hospital CoPs and Proposed Changes

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?

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 summary, medication orders, and more.

It will include the proposed changes in 2019 under the Hospital Improvement Rule. 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 CMS discharge planning standards and the proposed changes to transparency, including H&P changes, will also be covered.

CMS publishes a list of deficiencies received by hospitals and this will be discussed. The number of deficiencies in medical records section has gone up significantly. Come learn how to be compliant with these CMS requirements.

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.

It is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals move toward a completely integrated EMR. These should also be reflected in the hospital P&Ps. The number of deficiencies in each of the CMS medical records sections will be discussed.

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
• 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
• 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

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

Sue Dill Calloway
chief learning officer, Emergency Medicine Patient Safety Foundation

Sue Dill Calloway is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer.

Ms. Calloway has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.

Topic Background:

Most every hospital in the America accepts Medicare and Medicaid reimbursement and as such must be in compliance with the CMS Conditions of Participation (CoPs) for hospitals. There have been many changes to these over the recent past. This includes changes to Tag 454 (verbal orders), 457 (standing orders) and 458 (H&P update). Hospitals ask many questions regarding the regulations for standing orders, order sets, protocols, and preprinted orders.

There are several important CMS memos that have been published including an 11 page memo which addresses confidentiality and privacy. These are important in light of the recent large fines related to HIPAA being assessed by the Office of Civil Rights. This webinar will also discuss the OIG document on access verses authorization which is final and which is also discussed in the CMS proposed rules.

The medical records section has many important standards such as informed consent, history and physicals, verbal orders, discharge summaries and more. The CMS worksheet section about getting discharge summaries into the hands of the primary care doctor to prevent unnecessary readmissions will be discussed.

A discussion of the NOTICE law will be covered which requires a form to all observation patients. The IM notice and detailed notice forms have also been updated. The federal law on substance use disorder records also been amended.

Don’t be unprepared if the state department of health, state agency, or CMS shows up for a complaint or validation survey. Joint Commission has also recently changed many of their standards to comply with the CMS CoP requirements so not doing this right could also result in being out of compliance with standards from the Joint Commission. CMS states that all of their medical record regulations also apply to documents maintained by radiology and the lab.

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