Patient Rights and Medical Records
Restraint five changes
Change from LIP to licensed practitioner (LP)
Physician Assistants (PAs) to order and evaluate
Right to access medical records
Oral or written request
OCR 2016 2 documents
Non-discrimination
Written policy prohibiting
Inform each patient on prohibition against discrimination
Inform on how to file a complaint
Medical Records
Content of medical records
Document complications and hospital acquired conditions
Diagnosis in outpatient record in 7 days
Final diagnosis
Discharge instructions and transfer summaries
Will also discuss Nov 3, 2015 FR on proposed discharge planning standards related to discharge instructions and transfer summaries
Information to monitor patient conditions
QAPI
Quality indicator data including patient care data
Medicare Quality Reporting Data
Hospital readmission data
Hospital acquired conditions (HACs) and 5 changes
Nursing Services and Outpatient Departments
Staffing-adequate number
Supervisory staff
Need to respond immediately when needed
Nursing care plans
Policies and procedures
CNO must evaluate nursing staff including agency staff
All outpatient departments must identify if RN must be present
Outpatient policy required
P&P must be reviewed by MEC
Annual review of P&P
Orders for drugs and biologicals
Verbal orders
Infection Control and Antibiotic Stewardship
Hospital wide surveillance
Following national recognized standards and best practices
Infection control hospital wide QAPI program
Infection control program and policies requirements
Qualified infection preventionist
Requirements for the antibiotic stewardship program
Qualified leader who must be appointed by the board
Active program and evidenced based use of antibiotics
Document improvements and reduction of CDI
Board responsibilities
Responsibilities of leader of antibiotic stewardship program
Antibiotic stewardship policies
Tracking all infections
QAPI leadership
Competency based staff training
Restraint five changes
Change from LIP to licensed practitioner (LP)
Physician Assistants (PAs) to order and evaluate
Right to access medical records
Oral or written request
OCR 2016 2 documents
Non-discrimination
Written policy prohibiting
Inform each patient on prohibition against discrimination
Inform on how to file a complaint
Medical Records
Content of medical records
Document complications and hospital acquired conditions
Diagnosis in outpatient record in 7 days
Final diagnosis
Discharge instructions and transfer summaries
Will also discuss Nov 3, 2015 FR on proposed discharge planning standards related to discharge instructions and transfer summaries
Information to monitor patient conditions
QAPI
Quality indicator data including patient care data
Medicare Quality Reporting Data
Hospital readmission data
Hospital acquired conditions (HACs) and 5 changes
Nursing Services and Outpatient Departments
Staffing-adequate number
Supervisory staff
Need to respond immediately when needed
Nursing care plans
Policies and procedures
CNO must evaluate nursing staff including agency staff
All outpatient departments must identify if RN must be present
Outpatient policy required
P&P must be reviewed by MEC
Annual review of P&P
Orders for drugs and biologicals
Verbal orders
Infection Control and Antibiotic Stewardship
Hospital wide surveillance
Following national recognized standards and best practices
Infection control hospital wide QAPI program
Infection control program and policies requirements
Qualified infection preventionist
Requirements for the antibiotic stewardship program
Qualified leader who must be appointed by the board
Active program and evidenced based use of antibiotics
Document improvements and reduction of CDI
Board responsibilities
Responsibilities of leader of antibiotic stewardship program
Antibiotic stewardship policies
Tracking all infections
QAPI leadership
Competency based staff training
