Medical Record Chapter and Final Changes:  Meeting the CMS Hospital CoPs and New HIPAA Access Updates

This program will cover in detail the CMS regulations and interpretive guidelines for medical records. There will also be a brief discussion of the new Interoperability and Patient Access Rules and the pandemic 1135 waivers as some of the waivers affect medical records.

In April 2021, the 21st Century Cures Act on Interoperability, Information Blocking, and ONC Health IT Certification Program, also known as the Open Records Act, went into effect.  The new law affects healthcare providers and effectively grants patients immediate access to health information in their electronic medical record – without charge. Certain records are excluded, and the rule establishes eight exceptions to “information blocking’.This new rule and the implications for healthcare providers will be discussed.

This program will also cover some information on HIPAA from the Office of Civil Rights including the difference between patient access versus when an authorization is needed.

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

Learning Objectives:-

• Recall that CMS has specific informed consent requirements.
• Describe when history and physical must be done and what is required by CMS and the Joint Commission.
• Explain that both CMS and TJS have 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/other's access to health information.