Medical Record Chapter: Meeting the CMS Hospital CoPs and Access Requirements

This program will cover the CMS regulations and interpretive guidelines for medical records for acute and critical access hospitals in detail. 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.

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1. HOSPITAL CONDITIONS OF
PARTICIPATION (COPS) 2024
Medical Records Section
Presenter
Laura A. Dixon, BS, JD, RN, CPHRM
Healthcare Risk Education & Consulting, LLC
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2. 2
Speaker
•Laura A. Dixon, Esq.
•BS, JD, RN, CPHRM
•President, Healthcare Risk Education,
and Consulting, LLC
•303-955-8104
•[email protected]
•Email questions to CMS:
Critical Access Hospitals: [email protected].
Acute hospitals: [email protected].
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3. 3

4. CMS Deficiency Reports
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5. Patient Rights – Access to Medical
Records
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6. CMS Interoperability and
Patient Access Rule
“Open Notes” Rule
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7. Information Blocking
Cures Act Section 4004
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8. Conditions of Participation
Medical Records
Tag Nos. 431 – 471??
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9. Critical Access Hospitals CoPs
Clinical Records
Tag Nos. 1102 – 1128
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10. OCR – Security Risk
Assessment
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11. Copy/Paste
CMS and OIG Position
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12. Texting
CMS Update
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13. 13
The End Questions???
•Laura A. Dixon, Esq.
•BS, JD, RN, CPHRM
•President, Healthcare Risk Education,
and Consulting, LLC
•303-955-8104
•[email protected]
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