Home Events Medical Record Chapter: Meeting the CMS Hospital CoPs and Access Requirements

Medical Record Chapter: Meeting the CMS Hospital CoPs and Access Requirements


Date:  7/25/24

9:00 – 11:00 a.m.  Central time


Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.


This program will cover the Centers for Medicare & Medicaid Services (CMS) regulations and interpretive guidelines for medical records for Acute Care and Critical Access hospitals. There will also be a brief discussion of the Interoperability and Patient Access Rules. The law effectively grants patients immediate access to health information in their electronic medical record without incurring a charge. Certain records are excluded, and the rule establishes exceptions to “information blocking.” This rule and the implications for health care providers will be discussed. This webinar will present information on the Health Insurance Portability and Accountability Act (HIPAA) from the Office of Civil Rights (OCR), including differentiating between patient access and when an authorization is needed. There will also be a discussion on the standards that The Joint Commission (TJC) changed to comply with the CMS Conditions of Participation (CoPs)  requirements. Other topics to be discussed include security of health information and OCR Security Risk Assessment.

Learning 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.
– Recite that CMS has standards for pre-printed orders, standing orders, and protocols.
– Describe when healthcare providers can “block” patient/others’ access to health information.


Laura A. Dixon served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States As a registered nurse and attorney, Dixon holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

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



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Jul 25 2024


9:00 am - 11:00 am

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