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CMS Medical Records: Proposed Changes – Webinar

November 18 @ 9:00 am - 11:00 am

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CMS publishes a list of deficiencies received by hospitals and this will be discussed. The number of deficiencies in medical records section has gone up significantly. Come learn how to be compliant with these CMS requirements.

This program will cover some information on HIPAA from the Office of Civil Rights including the difference between patient access verses when an authorization is needed. Did you know that OCR is now fining hospitals if patients are not given access to medical records timely? The last two fines were $85,000 each.

It is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals move toward a completely integrated EMR. These should also be reflected in the hospital P&Ps. The number of deficiencies in each of the CMS medical records sections will be discussed.

Most every hospital in the America accepts Medicare and Medicaid reimbursement and as such must be in compliance with the CMS Conditions of Participation (CoPs) for hospitals. There have been many past changes to these over the recent past. This includes changes to Tag 454 (verbal orders), 457 (standing orders) and 458 (H&P update). Hospitals ask many questions regarding the regulations for standing orders, order sets, protocols, and preprinted orders.

There are several important CMS memos that have been published including an 11 page memo which addresses confidentiality and privacy. These are important in light of the recent large fines related to HIPAA being assessed by the Office of Civil Rights. This webinar will also discuss the OIG document on access verses authorization which is final and which is also discussed in the CMS final rules.

The medical records section has many important standards such as informed consent, history and physicals, verbal orders, discharge summaries and more. The CMS worksheet section about getting discharge summaries into the hands of the primary care doctor to prevent unnecessary readmissions will be discussed.

A discussion of the NOTICE law will be covered which requires a form to all observation patients. The IM notice and detailed notice forms have also been updated in 2020 also. The federal law on substance use disorder records also been amended.

Don’t be unprepared if the state department of health, state agency, or CMS shows up for a complaint or validation survey. Joint Commission has also recently 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 with standards from the Joint Commission. CMS states that all of their medical record regulations also apply to documents maintained by radiology and the lab.


  • 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 TJS have standards on verbal orders
  • Recall that CMS has standards for preprinted orders, standing orders, and protocols

Who Should Attend:

Director of Health Information Management, Health Information Management staff, Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO),  Compliance Officer, Director of Radiology, Lab Director, Hospital Legal Counsel, Joint Commission Coordinator, Quality Improvement Coordinator, Risk Managers, Nurse Educator, Patient Safety Officer, Emergency Dept. Manager, Nurse Managers/Supervisors, Staff Nurses, Clinic Managers, Medical Dept. Nurse Manager, Surgery Dept. Nurse Manager,  OR, ICU, CCI Nurse Directors, Outpatient Director, IS Director, Policy and procedure committee. Anyone involved in the implementation of the CMS or Joint Commission medical record and documentation standards.


$200 per facility/hospital