The Role of CMS in Setting Standards for Clinical Records

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@1100 words, 7 pages including cover sheet and sources. Written for HIT220, January, 2012

@1100 words, 7 pages including cover sheet and sources. Written for HIT220, January, 2012

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  • 1. Running head: The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 1 The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records Mary Strube January 22, 2012 Professor Theodos HIT 220 DeVry University Online
  • 2. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 2Table of ContentsIntroduction ..................................................................................................................................... 3Overview of CMS Standards .......................................................................................................... 3Standards of Clinical Record Content, Protection, and Retention and Preservation ...................... 4CMS Plays a Role in Setting Standards .......................................................................................... 5Conclusion ...................................................................................................................................... 6
  • 3. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 3Introduction The scope of this paper is to demonstrate the role of the Centers for Medicare andMedicaid Services (CMS) in setting standards regarding clinical health records. Although CMSis responsible for dozens of regulations regarding the clinical record, this paper will highlightonly a few in an attempt to show the relevance of the agency in setting standards of clinicalrecord content, maintenance, and retention and preservation. This paper is not designed to be acomprehensive listing of the regulations mandated by CMS, but merely to demonstrate theimportance of the agency as a standards-setting body.Overview of CMS Standards CMS is the branch of the United States Department of Health and Human Services thatadministers Medicare and the federal portion of the Medicaid programs. Because CMS is afederal body, regulations issued by them must be followed in every state. Due to its standing asa representative of the federal government, accrediting bodies, such as the Joint Commission,often refer to CMS guidelines when creating their own standards for accreditation. (Johns & al.,2011) Data taken from health records of Medicare patients are used by CMS to make decisionsregarding such things as reimbursement, the effectiveness of healthcare services, and the generaloverall health of patients who are covered by the CMS programs. These decisions are examined,and recommendations are made that, if followed, will result in an increase in the quality ofpatient care. These recommendations are collectively known as standards of quality, or
  • 4. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 4standards of care, and are a written description of features that are expected as a minimum levelof service to be provided in a healthcare environment. (Johns & al., 2011) CMS has taken their standards and compiled them into a list of requirements calledConditions of Participation (CoP). In order for a provider to receive reimbursement through theMedicare program, he must meet or exceed the requirements listed in the CMS CoP. Becausethe Joint Commission uses CMS guidelines as a basis for its accrediting process, any facility thatis accredited by the Joint Commission is considered by CMS to be in compliance with the CoP.(Johns & al., 2011) CMS has developed CoP standards to address all areas of a healthcare organization,including standards for the clinical record. CoP regulations regarding the clinical record can befound in the US statutes, Title 42, Volume 3, Chapter IV, Part 485. CMS regulations state that afacility is required to maintain a clinical record for each patient and that the record must bedocumented, accessible and organized to allow for ease of retrieval. Three standards arespecified in the statute: content, protection of information, and retention and preservation. (U.S.Government Printing Office, 2005)Standards of Clinical Record Content, Protection, and Retention and Preservation The content standard specifies what items are to be contained in the clinical record. Thecontent standard states that a clinical record must contain enough information so that the patientis clearly identified and to show that diagnoses and treatments are justified. Entries must betimely. Entries must be signed by the person providing care, and if this person is an "assistantlevel personnel," then the record must be countersigned by a supervisor. Specific documentation
  • 5. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 5requirements include initial assessment, plan of treatment, consent forms, medical history,physical exams, progress notes, and a discharge summary. (U.S. Government Printing Office,2005) There is a standard defining how data is to be maintained in the clinical record, referredto by CMS as protection. The standard of protection of clinical record content states that afacility must protect the record against unauthorized use, loss and destruction. Location-specificpolicies and procedures for the use, removal, and release of information must be in place insidethe facility. Any information that is protected must have the patients written consent before itcan be released to a third party. (U.S. Government Printing Office, 2005) Finally there are standards for the retention and preservation of clinical records. Thisstandard states that the facility must retain the clinical record for a period of 5 years followingdischarge of the patient. If the facility is no longer able to treat patients, it is required to makeprovisions for the maintenance of the clinical records of its former patients. (U.S. GovernmentPrinting Office, 2005)CMS Plays a Role in Setting Standards CMS plays a role in setting standards throughout the healthcare industry. Theirs are notthe only standards that are followed. Although CMS has printed rules regarding the clinicalrecord, actual standards vary between federal and state regulations, accrediting-body guidelines,and facility policies. It is important that all of these voices be heard rather than listening to onlyone. (Johns & al., 2011)
  • 6. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 6 One reason for this is because of ambiguity of the US statutes. For example, theMedicare COP as stated above require a retention period for clinical records of 5 years, but thefederal government allows civil penalties to be imposed for a period longer than 5 years. Thishas lead some states, such as Texas, to recommend retention periods longer than thoserecommended by CMS. (Texas Medical Association, 2007) It is common practice that the strictest standards available are the ones that are followed.Facilities look at all available information when designing policies and procedures with regardsto the clinical record. Content, maintenance, and retention and preservation guidelines arecreated and followed by a facility by keeping in mind all standards and rules from all accreditingand regulatory agencies that are relevant to the facility and its records, not just those of CMS.(Johns & al., 2011)Conclusion It is clear that CMS plays an important role in setting standards for quality healthcaredelivery in the United States. As a federal body, its recommendations serve as a basis forregulations issued by states and accrediting organizations. Using standards and guidelines issuedby various governing and regulatory bodies, facilities create local policies and proceduresregarding the content, maintenance, and retention and preservation of the clinical record. Manyagencies work toward the common goal of increasing the quality of patient care. CMS plays animportant role in the process.
  • 7. The Role of the Centers for Medicare and Medicaid Services in Setting Standards for Clinical Records 7Works Cited Johns, M. L., & al., e. (2011). Health Information Management Technology An AppliedApproach (Third ed.). Chicago: AHIMA Press. Texas Medical Association. (2007, September). rightnow.texmed.org/ci/fattach/get/7361.Retrieved January 2012, from rightnow.texmed.org:http://rightnow.texmed.org/ci/fattach/get/7361/ U.S. Government Printing Office. (2005, October 1). Section. Retrieved January 2012,from U.S. Government Printing Office:http://edocket.access.gpo.gov/cfr_2005/octqtr/42cfr485.60.htm