Medical Record Chapter: Meeting the CMS Hospital CoPs and Access Requirements
Description
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.
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.
- 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.
Webinar Details
Speaker
Laura A Dixon
Industry
Healthcare
Speciality
Nursing
Duration
90 Minutes
Laura A Dixon
(BS, JD, RN, CPHRM)
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. 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.