Medical Record: Compliance with CMS Hospital CoPs and Proposed Changes

CMS made changes to the hospital CoPs to include the history and physicals for healthy outpatients and discharge planning, plus access to medical records. In December 2020, HHS and the Office of Civil Rights (OCR) proposed changes to HIPAA and specifically, changes to strengthening individual patient access to their health information.  In September 2020, CMS made changes to electronic event notifications and impacting any provider who utilize and electronic medical record system.

This program will cover in detail the CMS regulations and interpretive guidelines for medical records. It includes hot issues like verbal orders, history and physicals, access to medical records, standing orders, discharge summary, medication orders, and more. 

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. 

This program will cover information on HIPAA from the Office of Civil Rights including the difference between patient access verses when an authorization is needed.  Also address will be regulations for standing orders, order sets, protocols, and preprinted orders. 

CMS also issued several important memos regarding medical records, including one that addressed confidentiality and privacy. These are important given 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 final rules, along with the December 2020 proposed changes to HIPAA.

There will be a discussion of MOON law which requires written information be given to all observation patients. The IM notice and detailed notice forms were updated in 2020 also. The federal law on substance use disorder records also been amended. Join this webinar to learn about the above changes and more. 

Webinar 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
• Recall that CMS has standards for preprinted orders, standing orders, and protocols

Webinar Agenda

• Introduction to the CMS hospital CoPs
• CMS Survey memos
• Confidentiality and privacy memo
• MOON form
• OCR information on HIPAA on patient access verses authorization
• TJC changes to comply with CoPs
• HITECH and Breech Notification law
• HHS/OCR rules on patient access
• E-Notification requirements
• Verbal orders and changes
• History and physicals
• Grievances
• Incident reports
• Medical record service requirements
• Content of records
• Standing orders and protocols
• 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 Should Attend

• Director of Health Information Management
• Health Information Management staff
• Chief Nursing Officer (CNO)
• Compliance Officer
• Director of Radiology
• 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