Medical Record Standards: What Hospitals Should Know About the CMS Hospital CoPs 2016

Key Topics

• How to obtain a copy
• Introduction to the CMS hospital CoPs
• Interpretive guidelines issued
• CMS Survey memos
• Confidentiality and privacy memo
• How to keep posted of new changes
• OCR new information on HIPAA
• Proposed changes to federal drug and alcohol drug
• Autopsies
• TJC changes to comply with CoPs
• HITECH and Breech Notification law
• AHIMA practice guidelines
• Verbal orders and changes
• Final changes to privacy, security, HITECH
• Grievances
• History and physicals
• Medical record service requirements
• Incident reports
• Author identification
• Medical record education and personnel
• Standing orders and protocols
• Content of records
• Informed consent
• Legibility and authentication requirements
• Discharge summaries
• List of procedures for consent requirements
• Completed medical records
• Other sections of CoPs that are important for documentation in the medical record

Who should Attend

Attendees from:

• Health Information Management staff
• Director of Health Information Management
• Compliance Officer
• Chief Nursing Officer (CNO)
• Lab Director
• Director of Radiology
• Chief Executive Officer (CEO)
• Hospital Legal Counsel
• Chief Medical Officer (CMO)
• Chief Operating Officer (COO)
• Quality Improvement Coordinator
• Joint Commission Coordinator
• Nurse Educator
• Risk Managers
• Emergency Department Manager
• Patient Safety Officer
• Staff Nurses
• Nurse Managers/Supervisors
• Medical Department Nurse Manager
• Clinic Managers
• OR Nurse Director
• Surgery Department Nurse Manager
• CCU Nurse Director
• ICU Nurse Director
• IS Director
• Outpatient Director
• Anyone involved in the implementation of the CMS or Joint Commission medical record and documentation standards
• Policy and procedure committee