Description
This program will cover in detail the CMS regulations and interpretive guidelines for medical records for Acute and Critical Access hospitals. There will also be a brief discussion of the new Interoperability and Patient Access Rules and the pandemic 1135 waivers as some of the waivers affect medical records.
In April 2021, the 21st Century Cures Act on Interoperability, Information Blocking and ONC Health IT Certification Program, also known as the Open Records Act, went into effect. The new law affects healthcare providers and effectively grants patient immediate access to health information in their electronic medical record – without charge. Certain records are excluded, and the rule establishes eight exceptions to “information blocking’. This new rule and the implications for healthcare providers will be discussed.
This program will also cover some information on HIPAA from the Office of Civil Rights including the difference between patient access verses when an authorization is needed.
There will also be a discussion on Joint Commission, which recently changed many of their standards to comply with the CMS CoP requirements.
Other topics to be discussed include CMS memo on texting, security of health information, history and physicals 2019 updates, and OIG and CMS position on copy/paste.
Session highlights:
- 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.
- Explain that both CMS and TJS have 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” patient/others access to health information.
Topics to be covered:
- Introduction
- Where to find the manuals
- Deficiency data related to medical records
- TJC standards and compliance
- CMS Standard of care and practice
- Changes to history and physical CoPs
- Hospital Improvement rule and applicable changes
- Patient rights and access to medical records
- Recent fines against hospitals – failure to provide records
- OCR rights of patients and access to records
- HIPAA Access vs. Authorization
- Interoperability and patient access rule
- Information blocking and when permitted
- Exceptions to Blocking rule
- CMS Memo on texting
- Conditions of participation
- MR services
- Staffing
- Retention of medical record
- Security and risk assessments
- Confidentiality and release of records
- Breach notifications
- 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
- Copy/Paste – OIG and CMS positions
Who should attend?
- Director of Health Information Management
- Health Information Management staff
- Chief Nursing Officer (CNO)
- Compliance Officer
- Director of Radiology
- 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
