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Medical Records: Compliance with CMS Hospital CoPs and Proposed Changes - Webinar

  • Webinar
  • 180 Minutes
  • November 2018
  • Compliance Online
  • ID: 4900007
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
AHIMA practice guidelines
HITECH and Breech Notification law
Final changes to privacy, security, HITECH
Verbal orders and changes
History and physicals
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


Sue Dill Calloway is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer.

Ms. Calloway has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.