Are you complying with the Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation (CoPs) regarding medical records requirements? Do you know what the CoP standards require of your hospital and each of its departments? If you’re unsure about your hospital’s compliance, you’re at risk for serious deficiencies.
The medical records CoPs contain a handful of all-too-common deficiency areas that CMS and state surveyors will be scrutinizing: informed consent, history and physical (H&P), medication orders, department organization, and more. That’s according to hospital compliance expert Sue Dill Calloway who explains how to avoid these red flag areas in her webinar, “Medical Records: How to Comply with CMS Hospital CoPs.”
Stop Before Sending that Text!
One hot-button issue is the texting of patient information—which has become such a prevalent problem and source of confusion that CMS had to issue a memo late last year for hospitals and critical access hospitals (CAH). CMS said:
- Texting patient information among members of the hospital and CAH healthcare team is permissible if done through a secure platform.
- Texting patient orders is prohibited regardless of the platform used.
- Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.
Both CMS and the Joint Commission have flip-flopped on their stance regarding texting patient information and orders, reported Healthcare IT News. But with the latest CMS memo, the two agencies’ requirements are more aligned.
To comply with the CoPs, all providers must use and maintain systems and/or platforms that are secure and encrypted—and minimize the risks to patient privacy and confidentiality as per HIPAA regulations and the CoPs, according to CMS Survey and Certification Group Director David Wright. You’re also expected to “routinely assess the security and integrity of the texting systems/platforms that are being utilized, in order to avoid negative outcomes that could compromise the care of patients.”
Key takeaway: So although your clinicians can use text messaging to exchange patient information among providers, texting physician orders—including any treatment orders—is a not allowed, period, Corridor stressed. Texting of physician orders does not meet the hospital Medicare CoPs.
Follow Specific Mandates on Physician Orders
Pay attention: The hospital CoPs for medical records state that the medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. For physician orders, the CoPs specifically mandate the following:
- All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.
- Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders only if the hospital:
- Establishes that such orders and protocols have been reviewed and approved by the medical staff and the hospital’s nursing and pharmacy leadership;
- Demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines;
- Ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols; and
- Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient’s medical record by the ordering practitioner or by another practitioner responsible for the care of the patient.
To Survive Surveys, Preparation Is Key
Bottom line: Make sure you understand the CMS hospital CoPs on medical records so you can avoid common deficiency areas, warns hospital compliance expert Sue Dill Calloway in her CoPs webinar. If you are well-versed in the hospital CoPs and stay current on CMS rule changes, you will be prepared for a surveyor’s visit to scrutinize your hospital’s compliance.