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CMS Revised Hospital CoPs on Standing Orders, Protocols, Order Sets & Pre-printed Orders
Introduction
- What are the CoPs
- How to locate a copy of the CoP
- Survey and Certification website for changes
- Definitions
- Joint Commission standards on standing orders
- CMS required radiology protocols
History
- History and development
- Tag 450 Changes
- A new tag number 457 was created
- final interpretive guidelines
Tag 457
- Use of pre-printed and electronic standing orders, order sets and protocols for patient orders and what criteria is met
- New tag number created under tag 457
- Tag 405 content moved to 457
- Orders and protocols review and approved by the medical staff
- Review by hospital’s nursing and pharmacy leadership
- Consistency with nationally recognized and evidenced based guidelines
- Periodic and regular review of orders and protocols by the Medical Staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols
- Dates, times, and authenticated in the medical record by the ordering physician or another physician who is responsible for the care of the patient
- The person signing off the order must be acting according to their scope of practice and in accordance with state law
Tag 405
- Most of the sections moved to tag 457
- Order needed for all drugs and biologicals
Tag 406
- Drugs and biologicals prepared on the orders contained in standing orders, protocols, and electronic standing orders
- Vaccines may be administered per physician-approved hospital policy after an assessment of the contraindications (MEC must approve the protocol)
- Orders for drugs and biologicals requirements
- Order for vaccine must later be signed by the physician
- An exception to having the order signed off (dated and timed) is flu and pneumovax
- Need to have an order for all drugs and biologicals
- Scope of practice issue
CMS Memo on Standing Orders in Hospitals
- Documenting as an order in the patient’s chart
- Requirements for signing off an order
- Requirements for a written set of orders, or is using a preprinted order set
- Physician or practitioner must identify the total number of pages
- documenting additions to preprinted orders, strike outs or deletions
- an electronic signature requirements for electronic orders
- State law and scope of practice requirements
- Protocols used to standardize and optimize patient care in accordance with clinical guidelines or standards of practice
- Implementation of evidenced based protocols or order sets to be used with patients diagnosed with MI, CHF, pneumonia or who are undergoing certain surgical procedures
- Formal protocols with code team or rapid response teams
- Pre-printed orders requirements
- All orders must be signed off, dated and timed
Tag 450
- All entries in the medical record must be legible and complete
- Every entry must be signed, dated, and TIMED
- Last page of the order sheet must identify the total number of pages, be dated, timed and signed off or authenticated
- The practitioner must initial every deletion, addition, strike out to preprinted orders
- Same principles apply to electronic order sets as far as signed, dated and time
Overview of the webinar
Are you aware of the requirements on standing orders promulgated by CMS that all hospitals must follow? This will also cover the Joint Commission standards on standing orders and protocols. Did you know there are four separate CMS hospital condition of participation sections that hospitals must be aware of? This program will cover the interpretive guidelines and regulations required by the Center for Medicare and Medicaid Services (CMS) related to Order Sets, Protocols, Preprinted Orders and Standing Orders.
This has been a very confusing area for hospitals and this program will demystify the changes and requirements. Any hospital that accepts Medicare or Medicaid patients must be in compliance with these standards and for all patients. This area has generated a large number of questions.
CMS created a tag number to house the major section regarding standing order requirements in the medical record chapter under Tag 457. There are a total of four separate sections in the hospital CoP manual that regulate this issue. This has been confusing for hospitals because two of the sections did not link to the other requirements in the CMS manual. CMS also moved most of the standing order requirements from tag 405 into the new section on tag 457. Standing orders must address well defined clinical scenarios. Standing orders related to medications must be approved by the Medical staff and nursing and pharmacy leadership. When CMS rewrote all the radiology standards in July of 2015 they required many radiology protocols and policies.
The development of protocols and standing orders is best described as a journey. This program will provide the history of each of the four sections and what each section requires hospitals to do. This program will clarify this confusing area and make the requirements understandable for hospitals. This is especially important as hospitals move toward a complete electronic medical record. It is important that any order in the electronic medical record populate the entire order in the order section.
Who should attend?
- CEO
- Chief Operating Officer
- Chief Nursing Officer
- Chief Risk Officer
- Chief Medical Officer
- Risk Management Professional
- Hospital Legal Counsel
- Senior Leadership
- Radiology Director
- PI Staff
- Compliance Officer
- Regulatory Officer
- Joint Commission Liaison
- Pharmacy Director
- Nurse Educator
- Pharmacist
- Rehab and Respiratory Director and Staff
- Patient Safety Officer
- MEC Committee Members
- Infection Preventionist or Manager
- Anesthesia Director
- Anesthesiologist
- Staff Nurses, Nurse Managers and Nurse Supervisors
- IS Department Staff
- Policy and Procedure Committee Members
- Anyone involved in Standing Orders, Protocols, Order Sets and Preprinted Orders
- Anyone who serves on a committee that reviews Standing Orders, Order Sets and Protocols
Why should you attend?
- Recall that hospitals must comply with the CMS CoP requirements if they accept Medicare or Medicaid reimbursement
- Discuss that CMS has requirements for standing orders and protocols in four separate sections
- Describe that all protocols must be approved by the Medical Staff even if the protocols are department specific
- Recall that the physician must sign off the standing order along with a date and time
Faculty - Ms.Sue Dill Calloway
Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal, patient safety, and risk management issues and writes numerous publications.
Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other healthcare providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, emergency department patient safety and risk, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year. She was the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program.