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Important CoP Clarification Regarding Physician Orders Documentation

Posted on Friday, January 5, 2018 2:48 PM

On December 28th, 2017, The Centers for Medicare and Medicaid Services (CMS) released a memorandum to State Survey Agency Directors reinforcing CMS’s position on the use of text messaging of patient information among healthcare providers.  This memorandum was released due to confusion related to text messaging in healthcare.

To clarify confusion on this topic, the memorandum states that text messaging of patient information among healthcare providers is acceptable as long as this is accomplished using a secure platform.  CMS states texting of any physician orders, including any treatment orders is prohibited regardless of the platform being used.  The clarification is based on hospital information, but is widely expected to be enforced across other healthcare providers including home health and hospice.

CMS contends the texting of physician orders does not meet the Medicare Conditions of Participation (CoPs) or the Conditions for Coverage.  The following is taken from the hospital Medicare CoPs for Medical Records:

  • 489.24(b) Standard: Form and retention of record. The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

Medical records must be retained in their original or legally reproduced form for a period of at least 5 years.

And

The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas.

  • 489.24(c) Standard: Content of record

(4) All records must document the following, as appropriate:

(i) Evidence of—

(vi) All practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition.

Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider. CMS has held to the long standing practice that a physician or Licensed Independent Practitioner (LIP) should enter orders into the medical record via a hand written order or via CPOE. An order if entered via CPOE, with an immediate download into the provider’s electronic health records (EHR), is permitted as the order would be dated, timed, authenticated, and promptly placed in the medical record.

Each of us recognizes that the use of texting as a means of communication with other members of the healthcare team has become an essential and valuable means of communication among the team members, especially in home care.  CMS recognizes this as well.   In order to be compliant with the CoPs or CfCs, all providers must utilize and maintain systems/platforms that are secure, encrypted, and minimize the risks to patient privacy and confidentiality as per HIPAA regulations and the CoPs or CfCs. It is expected that providers/organizations will implement procedures/processes that routinely assess the security and integrity of the texting systems/platforms that are being utilized, in order to avoid negative outcomes that could compromise the care of patients.

Although CMS clarification surrounds hospitals and references hospital CoPs, the same practice should be followed in all healthcare entities until regulations are changed and or clear language is provided that allows for the texting of physician orders.

Written by Peggy Patton RN, Corridor’s Vice President of Education Services


About Corridor

Corridor is a trusted home health and hospice consulting partner to agencies both large and small. We provide the most up-to-date comprehensive homecare industry educational resources and consulting available.

We specialize in delivering better revenue cycle management solutions, coding and documentation review services, regulatory compliance, and healthcare consulting.

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