Describe a Recent Change To CMS Regulatory Reporting Requirements and The Role of a Health Information Management (HIM) Professional in Ensuring an Organization is in Compliance

Describe a Recent Change To CMS Regulatory Reporting Requirements and The Role of a Health Information Management (HIM) Professional in Ensuring an Organization is in Compliance

Describe a Recent Change To CMS Regulatory Reporting Requirements and The Role of a Health Information Management (HIM) Professional in Ensuring an Organization is in Compliance

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The health care IT industry faces new challenges based on new health care insurance provider requirements, including evolving guidance from the Center for Medicare and Medicaid Services (CMS). Describe a recent change to CMS regulatory reporting requirements and the role of a health information management (HIM) professional in ensuring an organization is in compliance
Changes to CMS Regulatory Reporting Requirements and the Role of HIM Professional in Organizational Compliance
Healthcare system is marred with constant changes in rules and regulations. Similarly, the Center for Medicare and Medicaid Services (CMS) often change its rules and regulatory reporting requirements to ensure that patients under Medicare and Medicaid services are given the best and quality health care services possible.

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The recent change to CMS regulatory reporting occurred in the Fiscal Year (FY) 2020 Medicare Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-term Care Hospital (LTCH) Prospective Payment System Final Rule. Here, CMS initiated changes to the Promoting Interoperability Programs for Medicare eligible hospitals, dual-eligible hospitals attesting to CMS, and Critical Access Hospitals (CAHs) (CMS, 2020). The Final Rule approved policies to help in continued promotion of the use of certified electronic health record technology (CEHRT), lowering the burden, and enhance patient access and interoperability of health information. CMS requires the qualified settings and CAHs to effectively implement the CEHRT meaningful use to avoid their Medicare payments reduction (CMS, 2020).
It is imperative for every facility to assign a professional to receive the organization’s hospice quality information and ensure compliance with CMS regulations. As such, the organization can task the chief information officers (CIO) with the completion of this responsibility. The CIO has a role of managing the IT departments and also acts as the administrator who can successfully steer the organization in its bid to implement IT to enhance its strategic programs. Essentially, the CIO is tasked with taking charge of all operations of health IT. As such, it is the CIO’s role to ensure that all the facility’s health information is reported to the CMS (Abdolkhani et al., 2019).


Abdolkhani, R., Gray, K., Borda, A., & DeSouza, R. (2019). Patient-generated health data management and quality challenges in remote patient monitoring. JAMIA open, 2(4), 471-478.
CMS. (2020). 2019 Program Requirements Medicare. Retrieved from

In 1928, the Association of Record Librarians of North America was organized under the sponsorship of the American College of Surgeons (ACS) to elevate the standards of clinical records in hospitals, dispensaries, and other distinctly medical institutions.1 The ACS Manual of Hospital Standards provided direction as to what must be documented in patient records, how records should be maintained, and how to use record information to evaluate whether practices are in accordance with present-day scientific medicine.2 To enable record librarians to effectively assist healthcare organizations in meeting these standards, educational programs for librarians included training in quality-related activities. This is evidenced by June Winton’s description of one of her practicum assignments at St. Mary’s Hospital in 1936, during her senior year in the record librarian program at the College of St. Scholastica in Duluth, Minnesota:

Each student makes a group study of twenty-five cases under the direction of a member of the staff. Once the subject has been chosen and the doctor’s outline made, cases of the type desired are traced through the proper indices. After finding the charts in the filing room, we then assist in analyzing the cases for desired statistics and facts. When necessary to analysis, follow-up letters are sent to patients to ascertain post-hospital progress. Finally, the paper is assembled into useful form and typed. Our course in statistics proves as valuable in compiling these group studies as it is in making up daily, monthly and annual statistical reports.3

During her practicum, Winton learned how to collaborate with other professionals to formulate a study question and define study criteria. She used the criteria to gather information from records and directly from patients. She applied knowledge gained in her statistical course to prepare a report of the study findings. Although healthcare delivery has changed enormously since 1936, the skills Winton learned during her record librarian courses are comparable to tasks HIM professionals are doing today to support quality activities. The fundamental skills of data capture and reporting are still vitally important core HIM competencies. What has changed is the need for HIM professionals to be able to interpret and analyze performance results and effectively use information to improve healthcare quality. Driving this change is the accelerating scope and size of the quality movement.

Topic 1 DQ 1

What would spirituality be according to your own worldview? How do you believe that your conception of spirituality would influence the way in which you care for patients?

Spirituality is a broad concept with different perspectives from diverse people. Spirituality is important in human life, as it is considered both a motivating and harmonizing force. Further, spirituality is a difficult and multidimensional part of individuals’ life as an inner belief system. According to Polat and Ozdemir (2022), spirituality is an aspect of humanity that includes how people seek and express their meaning and purpose, and the way individuals experience connectedness to self, the moment, nature, others, and the sacred. Further, spirituality can be described as a set of beliefs that bring liveliness and meaning to the actions of life (Dewi & Hamzah, 2019). This indicates that spirituality is a significant dimension of people’s quality of life. Following the various descriptions of spirituality, spirituality can be described as seeking and expressing a meaningful connection with something greater than oneself, and a purpose of one’s existence to experience inner peace, love, hope, support, and comfort.

As nurses strive to provide holistic care to patients, spirituality influences nurses to address the spiritual needs of the patients. With spirituality being a key component in health and healing, spirituality influences nurses to lessen patients’ anxieties, provide hope, and empower patients to achieve inner peace by providing appropriate coping mechanisms and counseling during stressful situations. Nurses apply spiritual care to address patients’ needs of the spirit when they experience disease, fears, concerns, and sorrow (Polat & Ozdemir, 2022). Further spirituality influences nurses to provide therapeutic approaches that are based on compassionate relationships (Polat & Ozdemir, 2022). Spirituality allows nurses to care for the human spirit by developing caring and safe relationships and interconnectedness with patients to support spiritual well-being and health. Thus, spirituality is essential in nursing care. 


Dewi, D. S & Hamzah, H. B. (2019). The relationship between spirituality, quality of life, and resilience. Advances in Social Science, Education and Humanities Research, 349, 145-147.

Polat, H. T. & Ozdemir, A. A (2022). Relationship between compassion and spiritual care among nurses in Turkey. Journal of Religion and Health, 61, 1894-1905. 

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