History and Physicals: Understanding the CMS and Joint Commission Standards for Hospitals
Mar 09, 2021
90 Mins
Laura A. Dixon
CMS made a change effective November 29, 2019 regarding History and Physicals. Healthy outpatients may not be required to have a history and physical. Many hospitals are confused over what is required by hospitals in the CMS hospital Conditions of Participation Manual and by the Joint Commission standards. In fact, CMS noted in a past memo, that they frequently receive questions on this and in response CMS issues a clarification statement. The process to do will be explained including a required policy, Medical Staff and Board approval, revised medical staff bylaws and more. The webinar by industry expert Laura A. Dixon, BS, JD, RN will discuss what should be in the policy.
By attending this program, you 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 five separate tag numbers. CMS has also 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 including delegation of H&P, H&P for outpatient procedures, medical students doing H&Ps, podiatrist or dentist doing H&P, prenatal assessment, update requirements content of the H&P and authentication of H&Ps. Hospitals need to ensure that hospital policies and procedure meet the H&P requirements. Medical staff by-laws must also comply with the regulations and interpretive guidelines and standards.
Introduction to the CMS hospital CoP requirements
The Joint Commission H&P standards
Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. 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, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included 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.
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 insurance defense and representation of nurses before the Colorado Board of Nursing.
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.
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.
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Ligature Risks: Ensuring Compliance with the CMS Hospital CoPs and TJC Requirements
Recorded Webinar -
CMS Hospital Conditions Of Participation (CoPs) 2020: Revised Discharge Planning Standards
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