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.
It will include the proposed changes in 2018 under the Hospital Improvement Rule. 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.
Objectives of the Presentation
Why Should you Attend
- 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
CMS publishes a list of deficiencies received by hospitals and this will be discussed. The number of deficiencies in medical records section has gone up significantly. Come learn how to be too compliant with these CMS requirements.
This program will cover some 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 the changes to the federal law on alcohol and drug records which are now called substance abuse disorder records.
It is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals move toward a completely 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.
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). Hospitals ask many questions regarding 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 notice law will be covered which requires a form to all observation patients. The IM notice and detailed notice forms have also been updated. The federal law on substance use disorder records also been amended.
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.
Who will Benefit
- 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
- Final changes to federal drug and alcohol drug
- OCR new information on HIPAA
- TJC changes to comply with CoPs
- AHIMA practice guidelines
- HITECH and Breach Notification law
- Final changes to privacy, security, HITECH
- Verbal orders and changes
- History and physicals
- 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
- Pre-anesthesia 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
- 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