Medical Record: Compliance with CMS Hospital CoPs and Proposed Changes

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
120 minutes
Product Description

Learn About the Recent CMS Hospital CoP Changes and the Medical Records Standards

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.

Session Highlights

  • 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 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

Key Takeaways

  • Understand CMS specific informed consent requirements
  • Learn 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
  • Learn about CMS standards for preprinted orders, standing orders, and protocols

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

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

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...   More Info
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