This program will cover in detail the Centers for Medicare and Medicaid Services (CMS) regulations and interpretive guidelines for medical records. This is an extremely important section that includes verbal orders, history and physicals, access to medical records, standing orders, discharge summary, medication orders and more. CMS made changes to the hospital Conditions of Participation (CoPs) on Nov. 29, 2019, from two separate sets of federal regulations, including changes to histories and physicals for healthy outpatients and changes in discharge planning on access to medical records. The number of deficiencies in the medical records section has gone up significantly. Come learn how to be compliant with these CMS requirements.

This program will cover information on HIPAA from the Office of Civil Rights (OCR) including the difference between patient access versus when an authorization is needed. The OCR is now fining hospitals if patients are not given timely access to medical records. The last two fines were $85,000 each.

This program will also review several important CMS memos, including an 11-page memo addressing confidentiality and privacy. These are important in light of the recent large fines related to HIPAA being assessed by the OCR. This web conference will also discuss the Office of Inspector General (OIG) document on access versus authorization, which is also discussed in the CMS final rules.

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 and the Joint Commission (TJC)
  • Discuss that both CMS and TJC have standards on verbal orders
  • Recall that CMS has standards for preprinted orders, standing orders and protocols


Sue Dill Calloway, president, Patient Safety and Education Consulting

Sue Dill Calloway focuses on medical legal education, especially Joint Commission and CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. Previously, she was a director for risk management and patient safety for the Doctors Company. She was the vice president of legal services at a community hospital and served as the privacy officer and the compliance officer. She was also a medical malpractice defense attorney for 10 years and has three nursing degrees in addition to a law degree. She is a well-known lecturer and the first in the country to be a certified professional in CMS. She has written 102 books and thousands of articles.

Who should attend

CEOs, COOs, CMOs, CNOs, directors of health information management, compliance officers, directors of radiology, lab directors, hospital legal counsel,

Joint Commission coordinators, quality improvement coordinators, risk managers, nurse educators, managers and supervisors, patient safety officers and emergency department managers.

Continuing education

The program has been designed to meet the Minnesota Board of Nursing continuing education requirements for a total of 2 contact hours.


  • $200 per session for MHA member hospitals
  • $300 per session per organization for nonmembers

In order to allow for social distancing, pricing is set up per hospital rather than per connection. Please register just one person from your facility and have that person share the access information with others within your facility who wish to participate. Each hospital within a system must register separately.

Registration deadline

Please register by 5 p.m. on Oct. 16 to ensure timely delivery of access instructions. Once the deadline has passed, we will no longer be able to accept registrations.

Prior to the program you will receive an email that contains instructions on how to connect to the web conference. Advance registration is required to ensure delivery of instructional materials.

If you do not receive an email from Christy Hammer prior to the program with web conference details, please contact her at to confirm your registration.

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When and Where
  • 10/20/2020 9:00 AM CDT
  • 10/20/2020 11:00 AM CDT
  • Web Conference