WEBINAR: CMS Medical Records

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

Target Audience
Director of Health Information Management, Health Information Management staff, CNO, Compliance Officer, Director of Radiology, Lab Director, Hospital Legal Counsel, CEO, COO, 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 and anyone involved in the implementation of the CMS or Joint Commission medical record and documentation standards.

Webinar Topics:
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
AHIMA practice guidelines
HITECH and Breech Notification law
Final changes to privacy, security, HITECH 
Verbal orders and changes
History and physicals
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

Sue Dill Calloway, RN, Esq. CPRHM, AD, BA, BSN, MSN, JD, Attorney at Law
President of Patient Safety, Healthcare Consulting and Education Company

Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.

Ms. Calloway has given many presentations locally and nationally to nurses, physicians and attorneys on medical and legal issues. She has authored numerous articles and over 1000 articles and 100 books, including the 2009 Joint Commission Leadership Standard (HCPro), Nursing and the Law (PESI, 1986 and 1987), Ohio Nursing Law (West Publishing), Nursing Ethics and the Law (PESI, 1986), Legal Issues in Supervising Nurses (PESI, 1988), Medicine Made Easy (PESI, 1992) and The Law for Nurses Who Supervise/Manage Others (PESI, 1993), Legal Issues in Obstetrics (PESI, 1997) and JC Leadership Standards (HCPro, 2004), and the Compliance Guide to the CMS and the Joint Commission Patient Rights Standards (HCPro, 2005), and the 2009 book on the Joint Commission Leadership Standards (HCPro). She often writes articles called the “CMS Corner” in Briefings on the Joint Commission. Ms Calloway is a 1996 recipient of PESI's Excellence in Education Award.

Nursing CEU Credits: 
Nursing participants: This programhas been approved for 2.4 contact hours by the Iowa Board of Nursing Approved Provider Number 339. Completion of offering required prior to awarding certificate.
All other participants: Must attend the entire Webinar and complete a Webinar critique to receive a 2 Hour Attendance Certificate.
4/3/2017 9:00 AM - 4/3/2017 11:00 AM
United States


Monday, 03 April 2017

4/3/2017 9:00 AM
9:00 AM - 11:00 AM
4/3/2017 9:00 AM
4/3/2017 9:00 AM
9:00 AM - 11:00 AM
4/3/2017 9:00 AM

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