CMS SOM App. A, Tag A-1673

psychiatric hospitals.

(f) 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 §482.61(f)(1-4):

A psychiatric 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 psychiatric hospitals that do not have such 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), they are not required to be in compliance

with this standard.