ComplianceOnline

Medical Records: Compliance with CMS Hospital CoPs and Proposed Changes

Instructor: Sue Dill Calloway
Product ID: 705244
  • 12
  • July 2017
    Wednesday
  • 10:00 AM PDT | 01:00 PM EDT
    Duration: 90 Min

Live Online Training
July 12, Wednesday 10:00 AM PDT | 01:00 PM EDT | Duration: 90 Min

$199.00
One Dial-in One Attendee
$549.00
Group-Max. 10 Attendees/Location
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Get CD free on purchase of Group ticket

recorded version

$249.00
1x Person - Unlimited viewing for 6 Months
(For multiple locations contact Customer Care)
Recorded Link and Ref. material will be available in My CO Section 48 hrs after completion of Live training

Training CD

$349.00
One CD is for usage in one location only.
(For multiple locations contact Customer Care)
CD and Ref. material will be shipped within 15 business days after completion of Live training

Combo Offers

Live + Recorded Version

$349.00

Live + Training CD

$449.00

Customer Care

Fax: +1-650-565-8542

Email: customercare@complianceonline.com

Read Frequently Asked Questions

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?

Medical records is an extremely important section and includes hot issues like verbal orders, history and physicals, organization of the department, standing orders, discharge summaries, medication orders, and more. It will include the proposed changes in 2017 under the Hospital Improvement Act. 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 discharge planning standards, along with a federal law known as the IMPACT Act, would include revision of the transfer form, discharge planning evaluation form, nursing admission assessment form and would include five requirements for the discharge instructions. The discharge summary would need to be done and in the hands of the PCP within 48 hours. A discussion of the new Notice law or Moon form will be covered which requires a form to all observation patients.

CMS publishes a list of deficiencies received by hospitals and this will be discussed.

Learning 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
  • Discuss that both CMS and TJS have standards on verbal orders
  • Recall that CMS has standards for preprinted orders, standing orders, and protocols

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
  • Proposed changes to CMS discharge planning standards and what forms would need to be changed
    • Five requirements for discharge instructions
    • Changes to transfer form, admission assessment form and discharge planning form
  • How to keep posted of new changes
  • Confidentiality and privacy memo
  • Proposed changes to federal drug and alcohol drug
  • OCR new information on HIPAA
  • TJC changes to comply with CoPs
  • Autopsies
  • AHIMA practice guidelines
  • HITECH and Breach 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
Instructor Profile:
Sue Dill Calloway

Sue Dill Calloway
chief learning officer, Emergency Medicine Patient Safety Foundation

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.

Topic Background:

Mostly every hospital in the America accepts Medicare and Medicaid reimbursement and as such must be in compliance with the CMS Conditions of Participation (CoPs) for hospitals. There have been many changes to these over the recent past. This includes changes to Tag 454 (verbal orders), 457 (standing orders) and 458 (H&P update). CMS rewrote all the regulations for standing orders, order sets, protocols, and preprinted orders.

It is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals move toward an 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.

There are several important CMS memos that have been published including an 11 page memo which addresses confidentiality and privacy. These are important in light of the recent large fines related to HIPAA being assessed by the Office of Civil Rights.

Don’t be unprepared if the state department of health, state agency, or CMS shows up for a complaint or validation survey. Joint Commission has also recently changed many of their standards to comply with the CMS CoP requirements so not doing this right could also result in being out of compliance with standards from the Joint Commission. CMS states that all of their medical record regulations also apply to documents maintained by radiology and the lab.

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Refund Policy

Registrants may cancel up to two working days prior to the course start date and will receive a letter of credit to be used towards a future course up to one year from date of issuance. ComplianceOnline would process/provide refund if the Live Webinar has been cancelled. The attendee could choose between the recorded version of the webinar or refund for any cancelled webinar. Refunds will not be given to participants who do not show up for the webinar. On-Demand Recordings can be requested in exchange.

Webinar may be cancelled due to lack of enrolment or unavoidable factors. Registrants will be notified 24hours in advance if a cancellation occurs. Substitutions can happen any time.

If you have any concern about the content of the webinar and not satisfied please contact us at below email or by call mentioning your feedback for resolution of the matter.

We respect feedback/opinions of our customers which enables us to improve our products and services. To contact us please email customercare@complianceonline.com call +1-888-717-2436 (Toll Free).

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