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?
Almost every hospital in 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 including changes to Tag 454 (verbal orders), 457 (standing orders) and 458 (H&P update). CMS rewrote all 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.
In this session, expert speaker Sue Dill Calloway 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 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.
This session will cover a list of deficiencies published by CMS, which were received by hospitals. The number of deficiencies in medical records section has gone up significantly. This session will cover some new information on HIPAA from the Office of Civil Rights. It will 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. It is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals move towards an integrated EMR. These should also be reflected in the hospital P&Ps. Sue will discuss the number of deficiencies in each of the CMS medical records sections.
The medical records section has many important standards such as informed consent, history and physicals, verbal orders, discharge summaries and more. This session will discuss the CMS worksheet section about getting discharge summaries into the hands of the primary care doctor to prevent unnecessary readmissions. The requirements require the discharge summary to be completed and in the hands of the PCP within 48 hours. 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. You will get to discuss the new NOTICE law which requires a form to all observation patients. Sue will discuss proposed changes to the federal law on alcohol and drug records.
Don’t be unprepared if the state department of health, state agency, or CMS shows up for a complaint or validation survey. The 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.
Who Should Attend
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...
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