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Medical Records: Compliance with the Centers for Medicare and Medicaid Services (CMS) Hospital Conditions of Participation (CoPs) and Proposed Changes

August 20 @ 8:00 am - 10:00 am MDT

This program will cover the Centers for Medicare and Medicaid Services (CMS) regulations and interpretive guidelines for medical records. This is an extremely important section and includes hot issues like verbal orders, history and physicals, organization of the department, standing orders, discharge summaries and medication orders. It will include the 2019 proposed changes under the Hospital Improvement Rule, which contains changes to outpatient medical records, the rights of patients, and documentation changes. Our speaker will also cover information on HIPAA from the Office of Civil Rights. She will discuss important proposed changes to the CMS discharge planning standards and what will need to be documented in the medical record.

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 elements should also be reflected in the hospital P&Ps. The number of deficiencies in each of the CMS medical records sections will be discussed.

At the conclusion of this session, participants will be able to:

  1. Identify the CMS informed consent requirements.
  2. Describe when a history and physical must be completed and what is required by CMS and the Joint Commission.
  3. Discuss the CMS and TJC standards on verbal orders.
  4. Identify the CMS standards for pre-printed orders, standing orders and protocols.

Anyone involved in implementing the hospital CoPs, including CMOs, CNOs, nurses, nurse educators, TJC coordinator, quality improvement coordinator, risk managers, patient safety, regulatory and compliance officers, ED staff, hospital legal counsel, risk management, health information management staff and others interested in updates to medical records CoPs.

Sue Dill Calloway, President, Patient Safety and Health Care Education and Consulting

Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education & Consulting. She was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation.

The speaker has no real or perceived conflicts of interest that relate to this presentation.

August 13; 5:00 p.m. MDT – Registration fees are for one (1) connection.


Tickets are not available as this event has passed.


August 20
8:00 am - 10:00 am (MDT)
$160 – $320
Event Category:


Toni Pugmire
(208) 489-1409