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

Audience

chief medical officers, chief nursing officers, compliance officers, emergency department personnel, TJC coordinators, medical records staff, quality improvement personnel, risk managers and legal counsel

The following program content was provided by the speaker.

Overview

This program will cover the CMS regulations and interpretive guidelines for medical records for Acute Care and Critical Access hospitals. There will also be a brief discussion of the Interoperability and Patient Access Rules. The law effectively grants patients immediate access to health information in their electronic medical record without incurring a charge. Certain records are excluded, and the rule establishes exceptions to “information blocking.” This rule and the implications for health care providers will be discussed.

This virtual event will present information on HIPAA from the Office of Civil Rights, including differentiating between patient access and when an authorization is needed.

There will also be a discussion on the standards that TJC changed to comply with the CMS CoPs requirements.

Other topics to be discussed include security of health information and OCR Security Risk Assessment.

Objectives

Upon completion of this program, participants will be able to:

• • • recall that CMS has specific informed consent requirements
    • describe when a history and physical must be done and what is required by CMS
    • explain CMS standards on verbal orders
    • recite that CMS has standards for preprinted orders, standing orders and protocols
    • describe when health care providers can “block” patient/others’ access to health information

Speaker

Laura A. Dixon, B.S., J.D., R.N., CPHRM, most recently served as the Director of Risk Management and Patient Safety for the Colorado Region of Kaiser Permanente. Before joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states.

Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services and pain management. Before joining COPIC, she served as the Director of the Western Region, Patient Safety and Risk Management for The Doctors Company in Napa, Calif. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western U.S. As a registered nurse and attorney, Dixon holds a Bachelor of Science from Regis University in Denver; a Doctor of Jurisprudence from Drake University College of Law in Des Moines, Iowa; and a Registered Nurse diploma from Saint Luke’s School of Professional Nursing in Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.