CMS made changes to the hospital CoPs to include the history and physicals for healthy outpatients and discharge planning, plus access to medical records. In December 2020 and made changes to electronic event notifications and impacting any provider who utilizes an electronic medical record system. Additional changes were made in December 2020 regarding the interoperability of medical information.
This session will cover in detail the CMS regulations and interpretive guidelines for medical records. There will also be a brief discussion of the pandemic 1135 waivers as some of the waivers affect medical records.
In April 2021, the 21st Century Cures Act on Interoperability, Information Blocking, and ONC Health IT Certification Program, also known as the Open Records Act, went into effect. The new law affects healthcare providers and effectively grants patients immediate access to health information in their electronic medical record – without charge. Certain records are excluded, and the rule establishes eight exceptions to “information blocking’. This new rule and the implications for healthcare providers will be discussed.
There will also be a discussion on CMS regulations and interpretive guidelines for medical records. It includes much-discussed issues like verbal orders, history and physicals, access to medical records, standing orders, discharge summary, medication orders, and more.
Areas Covered in the Webinar
-Introduction to the CMS hospital CoPs
-Confidentiality and privacy memo
-IM and detailed notice forms
-Transfer form requirements and proposed changes
-OCR information on HIPAA on patient access verses authorization
-2021 changes to patient access and information blocking
-TJC changes to comply with CoPs
-HITECH and Breach Notification law
-Final changes to privacy, security, HITECH
-Verbal orders and changes
-History and physicals
-Medical record service requirements
-Medical record education and personnel
-Content of records
-Standing orders and protocols
-Legibility and authentication requirements
-List of procedures for consent requirements
-Completed medical records
-Other sections of CoPs that are important for documentation in the medical
Objectives / Agendas
-Recall that CMS has specific informed consent requirements.
-Describe when history and physical must be done and what is required by
CMS and the Joint Commission.
-Explain that both CMS and TJS have standards on verbal orders.
-Recall that CMS has standards for preprinted orders, standing orders, and
-Describe when and circumstances by which healthcare providers can “block”
patient/others access to health information.
Why You Should Attend
CMS regulations can be confusing if not overwhelming. Attending this webinar will
help clarify what is required by hospitals regarding medical record and compliance
with the Conditions of Participation.
Who Will Benefit?
-Director of Health Information Management
-Health Information Management staff
-Chief Nursing Officer (CNO)
-Director of Radiology
-Hospital Legal Counsel
-Chief Executive Officer (CEO)
-Chief Operating Officer (COO)
-Chief Medical Officer (CMO)
-Joint Commission Coordinator
-Quality Improvement Coordinator
-Patient Safety Officer
-Emergency Department Manager
-Policy and procedure committee
-Anyone involved in the implementation of the CMS or Joint Commission
medical record and documentation standards
You may ask your Question directly to our expert during the Q&A session.
Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.
Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.
Ms. Dixon’s legal experience includes medical malpractice defense and representation of nurses before the Colorado Board of Nursing.
As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.
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