Patient Rights and Medical Records
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Restraint five changes
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Change from LIP to licensed practitioner (LP)
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Physician Assistants (PAs) to order and evaluate
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Right to access medical records
-Oral or written request
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OCR 2016 2 documents
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Non-discrimination
-Written policy prohibiting
-Inform each patient on prohibition against discrimination
-Inform on how to file a complaint
-Content of medical records
-Document complications and hospital acquired conditions
-Diagnosis in outpatient record in 7 days
-Final diagnosis
-Discharge instructions and transfer summaries
*Will also discuss Nov 3, 2015, FR on proposed discharge planning standards related to discharge instructions and transfer summaries
-Information to monitor patient conditions
QAPI
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Quality indicator data including patient care data
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Medicare Quality Reporting Data
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Hospital readmission data
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Hospital-acquired conditions (HACs) and 5 changes
Nursing Services and Outpatient Departments
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Staffing-adequate number
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Supervisory staff
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Need to respond immediately when needed
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Nursing care plans
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Policies and procedures
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CNO must evaluate nursing staff including agency staff
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All outpatient departments must identify if RN must be present
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Outpatient policy required
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P&P must be reviewed by MEC
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Annual review of P&P
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Orders for drugs and biologicals
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Verbal orders
Infection Control and Antibiotic Stewardship
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Hospital-wide surveillance
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Following nationally recognized standards and best practices
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Infection control hospital-wide QAPI program
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Infection control program and policies requirements
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Qualified infection preventionist
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Requirements for the antibiotic stewardship program
-Qualified leader who must be appointed by the board
-Active program and evidenced based use of antibiotics
-Document improvements and reduction of CDI
-Board responsibilities
-Responsibilities of leader of antibiotic stewardship program
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Antibiotic stewardship policies
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Tracking all infections
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QAPI leadership
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Competency-based staff training