Cracking the Code to Standing Orders, Order Sets, and Preprinted Orders

Recorded Webinar | Virginia Pesata | From: Mar 21, 2019 - To: Dec 31, 2019

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. There are many required radiology protocols and policies and these will be discussed.

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.

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.

Agenda topics:-

  • What are the CoPs
  • CMS required radiology protocols
  • Tag 450 changes
  • Tag 457
  • Tag 405
  • Tag 406
  • Requirements for signing off an order
  • State law and scope of practice requirements
  • Pre-printed orders requirements

After this webinar, participants will be able to:-

  • 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.

Target Audience:-

Anyone involved in ensuring compliance with the CMS Hospital Conditions of Participation related to standing orders, protocols, order sets including the CEO, Chief Operating Officer, Chief Nursing Officer, Chief Risk Officer, Chief Medical Officer, Risk Management, 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, Nurse Supervisors, IS Department staff, Policy and Procedure Committee Members, and anyone involved in standing orders, protocols, order sets and preprinted orders. This includes anyone who serves on a committee that reviews standing orders, order sets, and protocols.

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