CMS Medical Records

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Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional Information

Provided by MHA Center for Education

Date & Time

Monday, April 3, 2017
9 - 11 a.m.

Register on or before Tuesday, March 28, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Additional phone line connections each will be charged a registration fee. Multiple participants on the same connection is encouraged. Get more value by inviting colleagues to join you!

This webinar is being offered at a reduced registration fee to MHA-member hospitals because of a contribution from MHA Management Services Corporation.


CEO, COO, CMO, CNO, director of health information management, health information management staff, compliance officer, director of radiology, lab director, hospital legal counsel, 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, outpatient director, policy and procedure committee

The following program content was provided by the speaker.


This webinar will cover in detail the Centers for Medicare & Medicaid Services’ regulations and interpretive guidelines for medical records. It will include the proposed changes in 2017 under the Hospital Improvement Act. The webinar also will cover new information on HIPAA from the Office of Civil Rights. It will discuss the important proposed changes to the CMS discharge planning standards and the necessary documentation to be included in the medical record.


  • recall that CMS has specific informed consent requirements
  • describe when a history and physical must be done and what is required by CMS and The Joint Commission
  • discuss that both CMS and TJC have standards on verbal orders
  • recall that CMS has standards for preprinted orders, standing orders, and protocols


  • Introduction to the CMS hospital CoPs
  • CMS survey memos
  • Interpretive guidelines issued
  • Proposed changes to CMS discharge planning standards and what forms would need to be changed
  • 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 Breech 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
    • Preanesthesia 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


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sue Dill Calloway is a nurse attorney and president of Patient Safety and Healthcare Consulting and Education Company. Calloway was the past vice president of legal services at a community hospital, in addition to being the privacy officer and the compliance officer. Calloway served as the director of risk management and health policy for more than eight years at the Ohio Hospital Association. She also was the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus, Ohio, for five years. She frequently lectures on legal and risk management issues and writes numerous publications. Calloway is a 1996 recipient of PESI HealthCare’s Excellence in Education award.