History and Physicals: Meeting Hospital CoPs in 2023

Webinar Details

Speaker

Laura A Dixon

Industry

Nursing

Speciality

Nursing

Available

All Days

Duration

90 Minutes


Registration Options

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Description

CMS made a change regarding History and Physicals. Specifically, healthy outpatients may not be required to have a full history and physical. The new process for this to occur will be explained including a required policy, Medical Staff and Board approval, revised medical staff bylaws, and more. The webinar will discuss what should be in the policy.

By attending this program, you can learn what is required to be in the history and physical and how to meet compliance with both the CMS hospital conditions of participation, the Joint Commission, and DNV standards. CMS has five separate sections that address history and physicals for Acute and CAHs.

Hospitals need to ensure that hospital policies and procedures meet the H&P requirements. Medical staff by-laws must also comply with the regulations interpretive guidelines and standards. The Joint Commission and DNV standards on history and physicals will be discussed.

Information on medical records deficiencies cited by CMS for both acute and critical access hospitals will be covered. Common deficiencies will show what CMS identifies during a medical record review.

Learning Objectives

  • Recall that CMS has H&P requirements in the hospital conditions of participation that all hospitals that accept Medicare must follow
  • Identify Joint Commission and DNV standards on H&P
  • Describe that the hospital must have medical staff by-laws and policies that include the requirements for H&Ps
  • Discuss what hospitals must do to implement the new rule that H&Ps do not need to be done on healthy outpatients

Outline

  • Introduction to the CMS hospital CoP requirements
  • CMS current hospital CoP manual
  • Cited deficiencies and how to locate
  • Recent changes – overall
  • H&P in the Medical Staff section
  • Medical staff by-laws
  • 24-hour update rule and the 30-day rule
  • Updates the day of surgery or procedure requiring anesthesia services
  • Who can perform an H&P
  • When an H&P is required
  • H&P on the chart before surgery
  • Documentation in the medical record
  • H&P done by a non-credentialed practitioner
  • CMS clarification memo
  • H&P in the Medical Records section
  • H&P in surgery services
  • CoP for H&Ps in Critical Access Hospitals
  • CAH requirements and new tag numbers

The Joint Commission Standards

  • Medical staff chapter
  • Provision of care chapter standards
  • Record of care chapter standards
  • Documenting H&P
  • MS by-laws
  • FAQ on H&P
  • Qualified physician and delegation
  • Practitioners without privileges
  • Medical students doing H&P
  • H&P for outpatient procedures
  • Podiatrist doing H&P
  • H&P for outpatient procedures
  • Authentication of H&P
  • Delegation of H&P
  • FAQs and prenatal records
  • Update requirements

DNV H&P Standards

  • Medical Staff section
  • Surgical Services section
  • Medical Records section

Appendix and Resources

Who Should Attend

  • Chief Medical Officer
  • Chief Nursing Officer
  • OR staff and OR nurses
  • Director of HIM
  • Outpatient nurses and staff
  • Surgery nurses
  • MS staff and physicians, PAs, and NPs
  • Risk Managers
  • Compliance Officers
  • Director of Regulatory Affairs
  • Outpatient Director
  • Joint Commission/DNV Director
  • Director of Health Information Management
  • Anyone involved in ensuring compliance with the history and physical requirements from the Joint Commission, DNV, and CMS hospital conditions of participation
Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura Dixon | Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, of the Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff in the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Laura Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

Registration Options

Choose Your Options

Save $20 - [ HEALTHCPTI ]

Error Conference Exists In Wish-list.

Congrats Conference Added In Wish-list.


Need Corporate Discount ?


  • * For more than 6 attendee call us at +1-800-803-7592 or mail us at cs@conferencepanel.com
  • * For Check and ACH payment call us at +1-800-803-7592 or mail us at cs@conferencepanel.com
  • * Click to download the Order Form
Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura Dixon | Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, of the Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff in the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Laura Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.