CMS Revised Hospital CoPs on Standing Orders, Protocols, Order Sets, & Preprinted Orders

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

Understand the CMS Interpretative Guidelines and Regulations in the Revised Hospital CoPs


Did you know all hospitals need to follow the requirements on standing orders published by CMS? This will also include the Joint Commission standards on standing orders and protocols. Additionally, there are four separate CMS hospital condition of participation sections that hospitals need to be aware of.

CMS created a tag number to house the major section regarding standing order requirements in the medical record chapter under Tag 457. There are a total of four separate sections in the hospital CoP manual that regulate this issue. This has been confusing for hospitals because two of the sections did not link to other requirements in the CMS manual. CMS also moved most of the standing order requirements from tag 405 into the new section on tag 457. Standing orders must address well defined clinical scenarios and those related to medications must be approved by the medical staff and nursing and pharmacy leadership. CMS rewrote all the radiology standards in July of 2015 and there are many required radiology protocols.

The development of protocols and standing orders are best described as a journey. In this session, expert speaker Sue Dill Calloway, RN, MSN, JD, will shed light on the history of each of the four sections and what each section requires hospitals to do. This program will clarify this confusing area and make the requirements understandable for hospitals. This is especially important as hospitals move toward a complete electronic medical record.

In a nutshell, Sue will review the interpretive guidelines and regulations required by the CMS related to Order Sets, Protocols, Preprinted Orders, and Standing Orders. This has been a very confusing area for hospitals and this program will demystify the changes and requirements. Any hospital that accepts Medicare or Medicaid patients must be in compliance with these standards and for all patients. This area has generated a large number of questions.

Session Highlights:

  • Why hospitals must comply with the CMS CoP requirements if they accept Medicare or Medicaid reimbursement?
  • Know the CMS requirements for standing orders and protocols in four separate sections.
  • How all protocols must be approved by the Medical Staff even if the protocols are department specific?
  • Why the physician must sign off the standing order along with a date and time?
  • Identify the critical changes to Tag numbers 405, 406 and 457.
  • The Joint Commission Standards on Protocols, Standing Orders and Order Sets.
  • Evaluate compliance requirements and penalties.

Session Agenda:

  • Hospital CoPs: History and Revisions
  • CMS Final Regulations
  • Final Interpretive Guidelines on Standing Orders
  • Location of CMS Hospital CoP Manual
  • Access to hospital compliant data
  • CMS Order Sets, Protocols, Standing Orders: What is the difference?
  • Updated deficiency data reports
  • Preprinted Orders Vs Order Sets
  • ISMP Guidelines for Order Sets
  • Changes to Heparin Power Plans and Infusions
  • CMS Memo on Standing Orders Oct 28, 2008
  • Minimum Requirements for Standing Orders
  • Revised Tag 405 and 406
  • Tag 405 Standing Orders 2014
  • Tag 405 Amended in 2014 & 2015
  • Final Federal Register Changes
  • Radiology Protocols
  • Anticoagulant Protocols
  • ACR Manual on contrast media
  • CHA guidelines and standing order

Who Should Attend?

CEO, Chief Operating Officer, Chief Nursing Officer, Chief Risk Officer, Chief Medical Officer, Risk Management, Hospital legal counsel, Senior Leadership, Radiology director, PI staff, Compliance Officer, Regulatory Officer, Joint Commission liaison, Pharmacy Director, Nurse Educator, Pharmacist, Rehab and Respiratory Director and staff, Patient Safety Officer, MEC committee members, Infection Preventionist, OR Manager, Anesthesia Director, Anesthesiologist, Staff Nurses, Nurse Managers, Nurse Supervisors, IS Department staff, Policy and Procedure Committee Members, and anyone involved in standing orders, protocols, order sets and preprinted orders. This includes anyone who serves on a committee that reviews standing orders, order sets, and protocols.

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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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