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.

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 CMS 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