Medical Record Chapter 2024 - Meeting the CMS Hospital CoPs, and Access Requirements

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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 patients immediate access to health information in their electronic medical records – without charge. Certain records are excluded, and the rule establishes exceptions to “information blocking’. This rule and its 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 versus when authorization is needed. There will also be a discussion on The Joint Commission, which changed many of its standards to comply with the CMS CoP requirements.

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

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.
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” patients/others' access to health information.

Detailed Agenda:-

Introduction
Deficiency of 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

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