Medical Record: Compliance with CMS Hospital CoPs and Proposed Changes


April 13, 2020


Sue Dill Calloway

  1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

* Not able to attend the live session? We can arrange an on-demand session for You. Please call 1-951-801-2324


If a CMS surveyor showed up at your door tomorrow would you know what to do? Are you up to date on all the recent CMS hospital CoP changes that went into effect November 29, 2019? Did you know that all the medical records standards (health information management) apply to all departments including lab and x-ray? Did you know that CMS made changes to the hospital CoPs on November 29, 2019 that were from two separate sets of federal regulations? This includes changes to the history and physicals for healthy outpatients. It also included some changes in the discharge planning on 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 informed consent, verbal orders, history and physicals, access to medical records, standing orders, discharge summary, medication orders, and more. 

This program will cover some information on HIPAA from the Office of Civil Rights including the difference between patient access verses when an authorization is needed. Did you know that OCR is now fining hospitals if patients are not given access to medical records timely? The last two fines were $85,000 each. 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.

There are several important CMS memos that have been published including an 11 page memo which addresses confidentiality and privacy. These are important in light of 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 verses authorization which is final and which is also discussed in the CMS final rules.

A discussion of the NOTICE law will be covered which requires a form to all observation patients. The IM notice and detailed notice forms have also been updated in 2020 also. The federal law on substance use disorder records also been amended. CMS states that all of their medical record regulations also apply to documents maintained by radiology and the lab.

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. Don’t be unprepared if the state department of health, state agency, or CMS shows up for a complaint or validation survey. Join this webinar to learn all the things you require to be in compliant.

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 and the Joint Commission
  • Discuss that both CMS and TJS have standards on verbal orders
  • Recall that CMS has standards for pre-printed orders, standing orders, and protocols

Who Should Attend?

    • Director of Health Information Management and Staff
    • Compliance Officer
      • Chief Nursing Officer (CNO), Nurse Managers/Supervisors and Nurse Director
      • Director of Radiology
      • Lab Director
      • Hospital Legal Counsel
      • C – Level Executives
      • Joint Commission and Quality Improvement Coordinator
      • Risk Managers
      • Patient Safety Officer
      • Emergency Department Manager
      • Clinic Managers
      • Outpatient Director
      • Policy and procedure committee