CMS SOM App. A, Tag A-0470

(d) Standard: Electronic notifications. If the hospital utilizes an electronic medical records

system or other electronic administrative system, which is conformant with the content

exchange standard at 45 CFR 170.205(d)(2), then the hospital must demonstrate that—

(1) The system's notification capacity is fully operational and the hospital uses it

in accordance with all State and Federal statutes and regulations applicable to

the hospital's exchange of patient health information.

(2) The system sends notifications that must include at least patient name, treating

practitioner name, and sending institution name.

(3) To the extent permissible under applicable federal and state law and

regulations, and not inconsistent with the patient's expressed privacy preferences,

the system sends notifications directly, or through an intermediary that facilitates

exchange of health information, at the time of:

(i) The patient's registration in the hospital's emergency department (if

applicable).

(ii) The patient's admission to the hospital's inpatient services (if

applicable).

(4) To the extent permissible under applicable federal and state law and

regulations, and not inconsistent with the patient's expressed privacy preferences,

the system sends notifications directly, or through an intermediary that facilitates

exchange of health information, either immediately prior to, or at the time of:

(i) The patient's discharge or transfer from the hospital's emergency

department (if applicable).

(ii) The patient's discharge or transfer from the hospital's inpatient

services (if applicable).

Interpretive Guidance §482.24(d)(1-4):

A hospital with an electronic health records system or electronic patient registration systems,

which are conformant with the content exchange standard HL7 2.5.1 at 45 CFR 170.205(d)(2),

are expected to use these systems to their full capacity to facilitate the notification of patient

admission, discharge, and transfer information in accordance with state and federal law. Upon

the consent of patient or the patient representative, at a minimum, the information exchange

must include the name of the patient, the practitioner responsible for the treatment of the patient,

and the name of the institution providing care to the patient. A patient or patient representative

does have the right to privacy and not permit the hospital to share this information through this

exchange. A patient’s refusal should be documented.

These requirements are applicable to all patients regardless of inpatient or outpatient status.

There may be instances of multiple admission notifications for one patient. For example, a

patient that enters through the emergency department (ED) are not admitted as an inpatient, but

the hospital would be responsible for sending a notification of the patient’s ED visit; and once

the patient is admitted as an inpatient, another notification would be sent as the patient has

changed their admission status.

Transfer notifications would be applicable for any patients who may be transferring to another

facility for additional needs or changes in level of care.

Discharge notifications would be applicable for all patient discharges from either inpatient or

outpatient admissions.

For hospitals that do not have such electronic medical records system or other electronic

administrative system, which is conformant with the content exchange standard HL7 2.5.1 at 45

CFR 170.205(d)(2), they are not required to be in compliance with this standard.