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Speaker |
Laura A Dixon |
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Industry |
Nursing |
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Speciality |
Nursing |
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Available |
All Days |
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Duration |
120 Minutes |
Description
If a CMS surveyor showed up at your door tomorrow would be prepared? Are you up to date on the changes that went into effect recently? Did you know that all the medical records standards apply to all departments including lab and x-ray?
CMS made changes to the hospital CoPs on November 29, 2019, from two separate sets of federal regulations. The changes include the history and physicals for healthy outpatients and discharge planning, specifically, access to medical records. It also included changes in the final Hospital Improvement rule. CMS also changed the website to get copies of all the manuals and the email address to ask questions so this information will be provided.
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, access to medical records, standing orders, discharge summary, medication orders, and more. There will also be a brief discussion of the pandemic 1135 waivers as the waivers affect medical records.
CMS publishes a list of deficiencies received by hospitals and this will be discussed. The number of deficiencies in the medical records section has gone up significantly.
This program will cover some information on HIPAA from the Office of Civil Rights including the difference between patient access versus when authorization is needed. OCR is now fining hospitals if patients are not given access to medical records timely. Recent fines were two for $85,000 each and one for $100,000.00.
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.
Most every hospital in America accepts Medicare and Medicaid reimbursement and as such must comply with the CMS Conditions of Participation (CoPs) for hospitals. There have been many past changes to these over the recent past. This includes changes to Tag 454 (verbal orders), 457 (standing orders), and 458 (H&P update). Hospitals ask many questions regarding the regulations for standing orders, order sets, protocols, and preprinted orders.
CMS also issued several important memos regarding medical records, including one that addressed confidentiality and privacy. These are important given the recent large fines related to HIPAA being assessed by the Office of Civil Rights. This webinar will also discuss the OIG document on access versus authorization which is final, and which is also discussed in the CMS final rules.
The CMS Conditions of Participation medical records section has many important standards including informed consent, history and physicals, verbal orders, discharge summaries, and more. The CMS worksheet section about getting discharge summaries into the hands of the primary care doctor to prevent unnecessary readmissions will be discussed.
There will be a discussion of MOON law which requires written information to be given to all observation patients. The IM notice and detailed notice forms were updated in 2020. The federal law on substance use disorder records has also been amended.
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 their medical record regulations also apply to documents maintained by radiology and the lab.
Learning Objectives
Agenda
Who Should Attend
(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.