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Medical Records: Compliance with CMS Hospital CoPs and Proposed Changes

  • Training

  • 120 Minutes
  • Compliance Online
  • ID: 4900007
This training program will cover in detail the CMS regulations and interpretive guidelines for medical records. It will also discuss important proposed changes to the CMS discharge planning standards including changes to the federal law on alcohol and drug records.

Why Should You Attend:

If a CMS surveyor showed up at your door tomorrow would you know what to do? Are you up to date on all the recent CMS hospital CoP changes? Did you know that all the medical records standards (health information management) apply to all departments including lab and x-ray?

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 summary, medication orders, and more.

It will include the proposed changes in 2019 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. The proposed changes to the CMS discharge planning standards and the proposed changes to transparency, including H&P changes, will also be covered.

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 compliant with these CMS requirements.

This program will cover some information on HIPAA from the Office of Civil Rights including the difference between patient access verses when an authorization is needed. It will discuss the changes to the federal law on alcohol and drug records which are now called substance abuse disorder records under 42 CFR Part 2.

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.

Areas Covered in the Webinar:

  • 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

  • How to keep posted of new changes
  • Confidentiality and privacy memo
  • MOON form
  • 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
  • AHIMA practice guidelines
  • 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
  • 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

Who Will Benefit:

  • Health Information Management Director
  • Health Information Management Staff
  • Chief Nursing Officer (CNO)
  • Compliance Officer
  • Radiology Director
  • 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


Sue Dill Calloway

Course Provider

  • Sue Dill Calloway
  • Sue Dill Calloway,