Description
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 utilize and electronic medical record system. Additional changes were made in December 2020 regarding 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 patient 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.
Objectives
- 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.
- Explain that both CMS and TJS have standards on verbal orders.
- Recall that CMS has standards for preprinted orders, standing orders, and protocols.
- Describe when and circumstances by which healthcare providers can “block” patient/others access to health information.
Agenda
- Introduction to the CMS hospital CoPs
- Confidentiality and privacy memo
- MOON form
- 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 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
Intended Audience:
- 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
