2018 - Medical Records: Compliance with CMS Hospital CoPs and Proposed Changes

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
Autopsies
AHIMA practice guidelines
HITECH and Breach Notification law
Final changes to privacy, security, HITECH
Verbal orders and changes
History and physicals
Grievances
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
Pre-anesthesia 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