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?
Most of the hospitals 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 over the recent past. This includes 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.
Donât 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. 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 program, expert speaker Sue Dill Calloway, RN, MSN, JD 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 is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals are moving toward an 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 in this session.
The session will also address the medical records section that has many important standards such as informed consent, history and physicals, verbal orders, discharge summaries and more. Additionally, it will cover the CMS worksheet section about getting discharge summaries into the hands of the primary care doctor to prevent unnecessary readmissions.
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. The discharge summary would need to be done and in the hands of the PCP within 48 hours. A discussion of the new NOTICE law will be covered which requires a form to all observation patients.
Who should attend
Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.
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 Events By The Speaker