History and Physicals: Meeting Hospital CoPs in 2021
  • CODE : DIXO-0002
  • Duration : 60 Minutes
  • Level : Intermediate
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Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners, and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty 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, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.

Ms. Dixon’s legal experience includes medical malpractice defense and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura 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.

CMS made a change effective November 29, 2019, regarding History and Physicals. Healthy outpatients may not be required to have a history and physical. The process to do this will be explained including a required policy, Medical Staff and Board approval, revised medical staff bylaws and more. The webinar will discuss what should be in the policy. Many hospitals are not familiar with what is required by hospitals in the CMS hospital Conditions of Participation Manual and by the Joint Commission standards.

By attending this program, attendees can learn what is required to be in the history and physicals and how to meet compliance with both the CMS hospital conditions of participation and with the Joint Commission standards. CMS has issued a deficiency memo so information will be given on how many hospitals received deficiencies in this area. This will also include the standards for critical access hospitals.

The Joint Commission has many frequently asked questions on H&Ps that will be discussed.

Areas Covered

  • Introduction to the CMS hospital CoP requirements
  • CMS current hospital CoP manual
  • Tag 358 and 359 on H&P in the Medical Staff section
  • Tag 461 and 463 on H&P in the Medical Records section
  • Tag 952 in surgery services
  • The new exception for healthy outpatients
  • How to draft a policy for the new exception
  • 24-hour update and the 30-day rules
  • Updates the day of surgery or procedure requiring anesthesia services
  • H&P on the chart before surgery
  • Exceptions for emergencies
  • Who can perform an H&P
  • When an H&P is required
  • Documentation in the medical record
  • H&P done by a non-credentialed practitioner
  • Requirements and new tag numbers

The Joint Commission and DNV H&P standards

  • Medical staff chapter
  • Record of care chapter standards
  • Provision of care chapter standards
  • Documenting H&P
  • 24 hour and the 30-day rule
  • MS by-laws
  • Qualified physician and delegation
  • FAQ on H&P
  • H&P for outpatient procedures
  • Medical students doing H&P
  • Podiatrist doing H&P
  • Prenatal record
  • Authentication of the H&P
  • H&P for an outpatient procedure

Course Level - Intermediate

Who Should Attend

  • Chief Nursing Officer
  • OR staff and OR nurses
  • Outpatient nurses and staff
  • Surgery nurses
  • Chief Risk Officer
  • MS staff and physicians, PAs and NPs
  • Risk Managers
  • Compliance Officers
  • Director of Regulatory Affairs
  • Outpatient Director
  • Hospital legal counsel
  • Joint Commission Director
  • Director of Health Information Management

Why Should You Attend

Unfamiliarity with the updates on History and Physicals from CMS – Centers for Medicare and Medicaid Services.

  • $149.00



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