Medical Record Standards: What Hospitals Should Know About the CMS Hospital CoPs

Duration: 90 Minutes
flat 40% off on this webinar use promo code
This program 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.
Medical Record Standards
Instructor: Sue Dill Calloway
Product ID: 501593
This program 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 will discuss proposed changes to the federal law on alcohol and drug records.

It is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals move 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.

Objectives of the Presentation
  • 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
  • Discuss that both CMS and TJS have standards on verbal orders
  • Recall that CMS has standards for preprinted orders, standing orders, and protocols
Why Should you Attend
Most every hospital in the 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.

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.

The medical records section has many important standards such as informed consent, history and physicals, verbal orders, discharge summaries and more. The CMS worksheet section about getting discharge summaries into the hands of the primary care doctor to prevent unnecessary readmissions will be discussed. 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.

Don’t 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.

Areas Covered
  • 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
Who can Benefit
  • 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
Note: Critical Access Hospitals (CAH) have a separate set of hospital CoPs and there are some difference in the medical record section although there are lot of similarities. CAH hospitals that are in systems should know the differences in the two sets of CoPs and may find the program of interest for that reason.
$300
Recorded Session for one participant
Get life time access with download option!
Book this course
Pay Now
  $450.00 Training CD
Free shipment within 4 Working Days of placing the order. Get life time access for unlimited participants.
  $550.00 Training USB Flash Drive
Free shipment within 4 Working Days of placing the order. Get life time access for unlimited participants.
For multiple location please contact our customer care team +1-510-857-5896.
How it works
Live Session - How it works
  • Login to onlinecompliancepanel with your registered username and password https://www.onlinecompliancepanel.com/login
  • The webinar joining link, username and password for joining the webinar will be updated on your OCP Account 24 hours prior to the webinar
  • Presentation handouts in Downloadable PDF format will be updated on your OCP Account 24 hours prior to the live session
  • Login to the audio conference on the scheduled date and time
  • Get answers to your queries through interactive Q&A sessions via chat at the end of the session
  • Download the Certificate of Attendance and Purchase Invoice from your OCP Account 24 hours after the completion of the session
  • Please let us know your thoughts and views at the end of the webinar, your valuable feedback will help us improve
Recorded Session - How it works
  • Login to onlinecompliancepanel with your registered username and password https://www.onlinecompliancepanel.com/login
  • Upon purchase of the recorded session a link will be updated on your OCP Account within 24 hours
  • Please click on the link to access the Recorded Session
  • Presentation handouts in downloadable PDF format will be updated on your OCP Account within 24 hours of the purchase of the product
  • Download the Certificate of Attendance and Purchase Invoice from your OCP Account after 48 hours of the product Purchase
  • Please share your valuable Feedback at the end of the session
Instructor Profile:
Sue is president of Patient Safety and Healthcare Consulting and Education company with 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 past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.
View More