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MEDICAL RECORD CHAPTER: MEETING THE CMS HOSPITAL COPS, AND ACCESS REQUIREMENTS

 Available : All Days  Presented By : Laura A. Dixon  Category : Healthcare
 Event Type : Recorded Webinar

For group or any booking support, contact:  cs@conferenceschedulers.com   1
(866) 755-8624 (US Toll Free)


Recording $229 Transcript $229 DVD $249 Recording & Transcript $399



DESCRIPTION

Introduction

This program will cover in detail the CMS regulations and interpretive
guidelines for medical records for Acute and Critical Access hospitals. There
will also be a brief discussion of the Interoperability and Patient Access
Rules. The law affects healthcare providers and effectively grants patient
immediate access to health information in their electronic medical record –
without charge. Certain records are excluded, and the rule establishes
exceptions to “information blocking’.  This rule and the 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 verses when an authorization is
needed.

There will also be a discussion on The Joint Commission, which changed many of
their standards to comply with the CMS CoP requirements.

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

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”
   patient/others access to health information. 

Detailed Agenda

 * Introduction
 * Deficiency data related to medical records
 * Patient rights to access medical records
 * Recent fines against hospitals
 * OCR rights of patients and access to records
 * HIPAA Access vs. Authorization
 * Interoperability and Patient Access Rule
 * Requirements for “Information blocking”
 * Conditions of Participation
   * MR services
   * Staffing
   * Retention of medical record
   * Security and risk assessments
   * Confidentiality and release of records
   * Content of record
   * Order sets
   * Rubber stamps
   * Verbal orders
   * Standing orders
   * History and physicals
   * Informed consent
   * Discharge summary
   * Electronic notifications

 * Critical Access Hospitals – clinical records CoPs
 * Breach notification
 * OCR – Risk Assessment
 * Copy/Paste – OIG and CMS positions
 * Texting of orders – CMS update

Appendix and Resources

Speaker

Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon recently served as the Regional Director of Risk Management and
Patient Safety for Kaiser Permanente Colorado where she provided consultation
and resources to clinical staff. Prior to joining Kaiser, she served as the
Director, Facility Patient Safety and Risk Management and Operations for COPIC
from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk
management consultation and training to facilities, practitioners, and staff in
multiple states. Such services included creation of and presentations on risk
management topics, assessment of healthcare facilities; and development of
programs and compilation of reference materials that complement
physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care
facilities, including critical care, coronary care, peri-operative services, and
pain management.

Prior to joining COPIC, she served as the Director, Western Region, Patient
Safety and Risk Management for The Doctors Company, Napa, California. In this
capacity, she provided patient safety and risk management consultation to the
physicians and staff for the western United States.

Ms. Dixon’s legal experience includes medical malpractice insurance defense and
representation of nurses before the Colorado Board of Nursing.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree
from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from
Drake University College of Law, Des Moines, Iowa, and a Registered Nurse
Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She
is licensed to practice law in Colorado and California

PRESENTED BY : LAURA A. DIXON

Laura A. Dixon served as the Director, Facility Patient Safety and Risk
Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon
provided patient safety and risk management consulting and training to
facilities, practitioners, and staff in multiple states.

Such services included the creation of presentations on risk management topics,
assessment of healthcare facilities; and development of programs and compilation
of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care
facilities, including critical care, coronary care, peri-operative services, and
pain management. Prior to joining COPIC, she served as the Director of, Western
Region, Patient Safety, and Risk Management for The Doctors Company, Napa,
California.

In this capacity, she provided patient safety and risk management consultation
to the physicians and staff in the western United States. Ms. Dixon’s legal
experience includes representation of clients for Social Security Disability
Insurance providing legal counsel and representation at disability hearings and
appeals, medical malpractice defense, and representation of nurses before the
Colorado Board of Nursing.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree
from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from
Drake University College of Law, Des Moines, Iowa, and a Registered Nurse
Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She
is licensed to practice law in Colorado and California.

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