Description 

This training program will provide an in-depth look at the CMS regulations and interpretive guidelines for medical records. It will also address significant updates to the CMS discharge planning standards, including recent changes to federal laws regarding alcohol and drug records.

Why you should Attend

If a CMS surveyor showed up at your door, would you know how to respond? Are you current on the latest CMS hospital CoP changes? It's important to recognize that all medical records standards (health information management) apply across all departments, including lab and x-ray.

This program will provide a detailed overview of the CMS regulations and interpretive guidelines for medical records. Key topics will include critical issues such as verbal orders, history and physicals, department organization, standing orders, discharge summaries, medication orders, and more.

We will also discuss changes under the Hospital Improvement Rule, including updates to outpatient medical records, patient rights, and documentation requirements. One notable proposal is to ensure that diagnoses and records are completed within seven days for outpatients. Additionally, we will cover the proposed changes to CMS discharge planning standards and transparency measures, including updates to history and physical documentation. CMS publishes a list of deficiencies identified in hospitals, and we will review this information. Notably, there has been a significant increase in deficiencies related to medical records. Join us to learn how to maintain compliance with these CMS requirements.

The program will also touch on HIPAA regulations from the Office of Civil Rights, highlighting the differences between patient access and situations requiring authorization. We will discuss updates to federal law regarding alcohol and drug records, now referred to as substance use disorder records under 42 CFR Part 2. As hospitals transition to fully integrated electronic medical records (EMR), it's crucial to ensure that all required CMS documentation elements are included and reflected in hospital policies and procedures. We will review the number of deficiencies noted in each CMS medical records section.

Areas covered in Session 

• Introduction to the CMS hospital CoPs
• How to obtain a copy
• CMS Survey memos
• Interpretive guidelines issued

1. Changes to verbal orders, standing orders and H&P update

• How to keep posted of new changes
• Confidentiality and privacy memo
• Moon Form
• Confidentiality and privacy memo
• IM and detailed notice forms
• Transfer form requirements and proposed changes
• Final changes to federal drug and alcohol drug 42 CFR Part 2
• OCR information on HIPAA on patient access verses authorization
• TJC changes to comply with CoPs
• Autopsies and AHIMA practice guidelines
• HITECH and Breech Notification law
• Final changes to privacy, security, HITECH
• Verbal orders and changes
• Grievances, Incident reports
• Medical record service requirements
• Author identification, Content of records
• Other sections of CoPs that are important for documentation in the medical record

Session Highlights

Most hospitals in the U.S. accept Medicare and Medicaid reimbursement, necessitating compliance with CMS Conditions of Participation (CoPs). Recent changes include updates to Tag 454 (verbal orders), Tag 457 (standing orders), and Tag 458 (H&P updates). Hospitals frequently have questions about regulations regarding standing orders, order sets, protocols, and preprinted orders. Several key CMS memos have been issued, including an 11-page document on confidentiality and privacy, particularly relevant due to recent substantial HIPAA fines imposed by the Office of Civil Rights. This webinar will also cover the OIG document on access versus authorization, which aligns with CMS proposed rules.

Important standards in the medical records section include informed consent, history and physicals, verbal orders, and discharge summaries. We will discuss the CMS worksheet focusing on delivering discharge summaries to primary care doctors to prevent unnecessary readmissions. Additionally, we’ll address the NOTICE law, which mandates a form for observation patients, along with updates to the IM notice and detailed notice forms. Changes to federal laws on substance use disorder records will also be highlighted.

Who should Attend

• Health Information Management Staff and Director 
• C-Level Executives including Chief Nursing Office, CEO, COO, CMO etc
• Radiology and Lab Director
• Hospital Legal Counsel
• Joint Commission Coordinator
• Quality Improvement Coordinator
• Nurse Managers/Supervisors
• Emergency Department Manager
• Patient Safety Officer
• Anyone involved in the implementation of the CMS or Joint Commission medical record and documentation standards