Medical Records: Compliance with CMS Hospital CoPs and Proposed Changes

If a CMS surveyor showed up at your door tomorrow would you know what to do? Are you up to date on all the recent CMS hospital CoP changes? Did you know that all the medical records standards (health information management) apply to all departments including lab and x-ray?

Medical records is an extremely important section and includes hot issues like verbal orders, history and physicals, organization of the department, standing orders, discharge summaries, medication orders, and more. It will include the proposed changes in 2017 under the Hospital Improvement Act. This includes changes to outpatient medical records, the rights of patients, and documentation changes. One proposed change would require that the diagnosis and records be completed within 7 days for outpatients.

The proposed changes to the discharge planning standards, along with a federal law known as the IMPACT Act, would include revision of the transfer form, discharge planning evaluation form, nursing admission assessment form and would include five requirements for the discharge instructions. The discharge summary would need to be done and in the hands of the PCP within 48 hours. A discussion of the new Notice law or Moon form will be covered which requires a form to all observation patients.

CMS publishes a list of deficiencies received by hospitals and this will be discussed.