Medical Record Chapter: Meeting the CMS Hospital CoPs, and Access Requirements

Description

Introduction

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 Interoperability and Patient Access Rules. The 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 exceptions to “information blocking’.  This rule and the 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 verses when an authorization is needed.

There will also be a discussion on The Joint Commission, which changed many of their standards to comply with the CMS CoP requirements.

Other topics to be discussed include security of health information and OCR Security Risk Assessment.

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” patient/others access to health information. 

Detailed Agenda

• Introduction
• Deficiency data related to medical records
• Patient rights to access medical records
• Recent fines against hospitals
• OCR rights of patients and access to records
• HIPAA Access vs. Authorization
• Interoperability and Patient Access Rule
• Requirements for “Information blocking”
• Conditions of Participation
  • MR services
  • Staffing
  • Retention of medical record
  • Security and risk assessments
  • Confidentiality and release of records
  • 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
• Breach notification
• OCR – Risk Assessment
• Copy/Paste – OIG and CMS positions
• Texting of orders – CMS update

Appendix and Resources

Speaker

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, 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 creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

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.

Prior to joining COPIC, she served as the Director, 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 for the western United States.

Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

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