Medical Record Chapter: Meeting the CMS Hospital CoPs and Access Requirements

This program will cover the CMS regulations and interpretive guidelines for medical records for acute and critical access hospitals in detail. There will also be a brief discussion of the Interoperability and Patient Access Rules. The law affects healthcare providers and effectively grants patients immediate access to health information in their electronic medical records – without charge. Certain records are excluded, and the rule establishes exceptions to “information blocking’.  This rule and its implications for healthcare providers will be discussed.

This program will revisit information on HIPAA from the Office of Civil Rights, including the difference between patient access versus when authorization is needed. There will also be a discussion on The Joint Commission, which changed many of its standards to comply with the CMS CoP requirements.

Other topics to be discussed include the security of health information and OCR Security Risk Assessment.

• Recall that CMS has specific informed consent requirements.
• Describe when a history and physical must be done and what is required by CMS.
• Explain both CMS and The Joint Commission standards on verbal orders.
• Recall that CMS has standards for preprinted orders, standing orders, and protocols.
• Describe when and circumstances by which healthcare providers can “block” patients/others' access to health information. 

• Introduction.
• Deficiency of data related to medical records.
• Patient rights to access medical records.
• Recent fines against hospitals.
• OCR rights of patients and access to records.
• HIPAA Access vs. Authorization.
• Interoperability and Patient Access Rule.
• Requirements for “Information Blocking.”
• Conditions of Participation
  • MR services.
  • Staffing.
  • Retention of medical records.
  • Security and risk assessments.
  • Confidentiality and release of records.
  • Content of record.
  • Order sets.
  • Rubber stamps.
  • Verbal orders.
  • Standing orders.
  • History and physicals.
  • Informed consent.
  • Discharge summary.
  • Electronic notifications.
• Critical Access Hospitals – Clinical Records CoPs.
• Breach notification.
• OCR – Risk Assessment.
• Copy/Paste – OIG and CMS positions.
• Texting of orders – CMS update.
• Appendix and Resources.