Catalog Number : ngd1567
Title : CMS Medical Records
Speaker : Sue Dill

Webplay Recording Date : 5-4-2016
Webplay Price : $ 150 for two weeks viewing

Webinar Description:

This webinar will cover in detail the CMS regulations and interpretive guidelines for medical records. It will include the proposed changes in 2017 under the Hospital Improvement Act.

This webinar will also cover some new information on HIPAA from the Office of Civil Rights. It will discuss the important proposed changes to the CMS discharge planning standards and the number of things that will need to be documented in the medical record.

Webinar Objectives:

• Recall that CMS 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 TJC have standards on verbal orders
• Recall that CMS has standards for preprinted orders, standing orders, and protocols

Target Audience:

Director of HIM, HIM Staff, CNO, Compliance Officer, Director of Radiology, Lab Director, Hospital Legal Counsel, CEO, COO, CMO, Quality Improvement Coordinator, Risk Managers, Nurse Educators, Patient Safety Officer, ED 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 Directors, Policy and Procedure Committee and anyone involved in the implementation of the CMS or JC Medical Record or Documentation Standards

A few of the topics to be discussed:

• Introduction to the CMS hospital CoPs
• How to obtain a copy
• CMS Survey memos
• Interpretive guidelines issued
  • Changes to verbal orders, standing orders and H&P update
• Proposed changes to CMS discharge planning standards and what forms would need to be changed
  • Five requirements for discharge instructions
  • Changes to transfer form, admission assessment form and discharge planning form
• How to keep posted of new changes
• Confidentiality and privacy memo
• Proposed changes to federal drug and alcohol drug
• OCR new information on HIPAA
• TJC changes to comply with CoPs
• Autopsies
• AHIMA practice guidelines
• HITECH and Breech Notification law
• Final changes to privacy, security, HITECH
• Verbal orders and changes
• History and physicals
• Grievances
• Incident reports
• Medical record service requirements
• Medical record education and personnel
• Author identification
• Content of records
• Standing orders and protocols
• Legibility and authentication requirements
• Informed consent
• List of procedures for consent requirements
• Discharge summaries
• Completed medical records
• Other sections of CoPs that are important for documentation in the medical record
  • Restraint and seclusion
  • Medication documentation
  • Preanesthesia assessment
  • Post anesthesia assessment
  • Visitation with changes to advance directives, consent and plan of care
  • Notification of OPO in deaths
  • Organ donation documentation
  • Anesthesia standards

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.