Catalog Number : ngd1714
Title : The Joint Commission IM Standards Update
Speaker : Sue Dill

Webplay Recording Date : 3-10-2014
Webplay Price : $ 125 for two weeks viewing

Webinar Purpose:

This webinar will cover the 8 standards in the current Joint Commission Information Management (IM) chapter. Planning is an important part of the IM chapter for medical records. Maintaining privacy has become much more challenging especially in the electronic era. Violation of the privacy standard can result in patients being able to sue, action by the Office of Civil Rights, enforcement by the state attorney general, compliance issue with both the Joint Commission and Center for Medicare and Medicaid Services (CMS) and more. This is also important in light of increased HIPAA audits. This has become more detailed in light of HITECH and recent federal laws and final changes to HITECH, privacy and security rules effective September 23, 2013. Hospitals are under more scrutiny to protect patient confidentiality.

The proposed consumer reporting system and how this could affect the health information management staff and hospitals will be discussed. Additional material will be provided to discuss some of the important changes to the September 23, 2013 HIPAA law that are contained in the Joint Commission IM Chapter.

Webinar Objectives:

• Recall that the Joint Commission has 8 standards in the IM chapter
• Discuss that the hospital must have a written policy addressing the privacy of health information
• Describe that medical records must be accessible 24 hours a day
• Recall that there are requirements regarding abbreviations used in hospitals
• Discuss that CMS has issued a 11 page memo on confidentiality and privacy that applies to hospitals

Target Audience: 

Health Information Management Staff and Director, Privacy and security officers, nurse managers, chief nursing officer, regulatory officer, Joint Commission coordinator, Chief Medical Officer, Physicians, Nurses, Audit staff, CMS regulatory director, nurses, nurse educator, Risk Managers, Legal Counsel, Compliance Officer, Privacy Officer, Security Officer, Chief Operating Officer, IS staff, Department Directors, and anyone involved with medical record issues and ensuring privacy and confidentiality of medical records

A Few of the Topics that will be covered:

• CMS Privacy and Security Memo
• September 23, 2013 HIPAA changes
• CMS June 7, 2013 changes on protocols, order sets, standing orders
• Plans for managing information
• Plans for continuity of its information management processes
• Discussion of topics now in the RC chapter
• Protecting the privacy of health information
• Policy on terminology and abbreviations uses
• Identifying internal and external data to provide safe care
• Required policies
• When medical records can be removed from the hospital
• Maintaining security and integrity of health information
• Retrieval, dissemination, and transmittal of health information
• Accurate health information
• Protecting medical records against loss, damage, or theft
• Monitoring compliance with policies
• Records accessible 24 hours a day
• Knowledge based information resources must be available, current, and authoritative
• Do not use abbreviations
• Discussion of IM standards that now appear in the RC chapter
• Cross walk of IM standard to CMS hospital conditions of participation chapter regulations
• Recent changes
• IM.02.02.03 CAH rehab or psych units storage and retrieval systems changes
• CMS memo on legibility of physician signatures and stamps
• Certificate of destruction
• HIPAA proposed accounting of disclosure
• Unannounced HIPAA audits
• Retention and destruction
• Federal and state law retention periods

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.