The CMS issued its final interpretive guidelines for medical records on October 17, 2008 with amendment on June 5, 2009. There have been many changes to these since the last publication. The Joint Commission has also changed many of their standards to comply with the CMS CoP requirements, so not doing this right could also result in being out of compliance. 

How can you be prepared if the state department of health or CMS shows up for a complaint or validation survey? In this 90 minute audio conference, nurse attorney Sue Dill Calloway will cover in detail the CMS regulations and interpretive guidelines for medical records. She will address:

• Introduction to the CMS hospital CoPs
• How to obtain a copy
• How to keep posted of new changes
• TJC July 2009 changes to comply with CoPs
• Autopsies
• Verbal orders
• 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
  • Preanesthesia assessment
  • Post anesthesia assessment
  • Notification of OPO in deaths
  • Organ donation documentation

Learning Objectives:

• Discuss the CMS section on medical records services revised on October 17, 2008 and June 5, 2009.
• Describe what is required by CMS and the Joint Commission regarding patient history and physicals.
• Discuss the CMS and TJC standard on verbal orders.

Target Audience:

• Director of Health Information Management
• Chief Nursing Officer (CNO)
• Compliance Officer
• Director of Radiology
• Lab Director
• Hospital Legal Counsel
• Chief Executive Officer (CEO)
• Chief Operating Officer (COO)
• Chief Medical Officer (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
• Policy and procedure committee
• Anyone involved in the implementation of the CMS or Joint Commission medical record and documentation standards

Level: ALL levels

Meet Your Expert!

Sue Dill Calloway is a nurse attorney and medical legal consultant. She is also the Director of Hospital Patient Safety and Risk Management for the Doctors Company. She has been a medico-legal consultant for more than 25 years. She has presented many educational programs for nurses, physicians, and other health care providers. Some of the topics include: nursing law, HIPAA medical record confidentiality, Joint Commission issues, CMS issues, medication/medical errors, documentation, pain management, federal laws for nursing, patient safety, and other similar topics.

Sue earned her MSN in nursing, summa cum laude, and JD with honors from Capital University in Columbus, Ohio.

Continuing Education:

Participation:

Each listener participates in the continuing education activity by listening to the audio conference and completing the online post test and evaluation.

Accreditation Statement:

AHC Media is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Credit Designation:

This activity has been approved for 1.5 nursing contact hours using a 60-minute contact hour.

Provider approved by the California Board of Registered Nursing, Provider # 14749, for 1.5 Contact Hours.

Sponsor:

The sponsor of this educational activity is AHC Media.

The information provided in AHC Media audio conferences does not, and is not intended to constitute medical diagnoses or legal advice. Individual tracer methodology outcomes cannot be guaranteed. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.

Recorded: Wednesday, April 14, 2010