Credentialing and Medical Staff Records


Audio Conferences
		Disruptive Behavior and the Joint Commission's Sentinel Event Alert New Gainsharing Exception The Sixteen Step Program
Audio CDs/MP3s
	AHP Potpourri Board Conflicts of Interest The "Borderline" Physician: Managing Performance Improvement for Those Who Can Improve (and Building the Legal Record for Those Who Can't) Charity Care Class Action Lawsuits Clinical Privileges: Tough Issues and Solutions CMS Clarification on Hospital Privileging CMS Issues Final Rule on 4 CoPs CMS: The New Guidelines for Informed Consent - Process, Policies and Forms Community Need for Physicians: How to Analyze, Prove and Document It Conduct Outside the Hospital: Are You Your Brother's Keeper? Conflicts of Interest on the Medical Staff Contracting and Credentialing: Bridge the Gap or Pay the Piper Corporate Bylaws: When Was the Last Time You Looked Yours Over? Credentialing and Medical Staff Records - Access, Control and Confidentiality Credentialing and Privileging Teleradiologists The Credentialing Process: Who is Slipping Through the Cracks? Credentialing the Aging Physician Credentialing Verification in the Trenches Criminal Background Checks for Physicians Deferred Compensation for ER Call Effective Performance Improvement Plans Employing Physicians Series EMTALA and On-Call: Important New Changes EMTALA: The Final Rule and Regulations EMTALA Guidelines EMTALA Investigations: How to Survive Excess Benefit Transactions Exclusive Contracts - Strategies to Deal with the Shortage of Doctors Executive Compensation in IRS Crosshairs Fair Market Value The Feds Are Coming – Do You Know Where Your Physician Contracts Are? Forgoing Life Sustaining Treatment Fraud, Abuse & the OIG: A Look Back — A Look Ahead Free Speech or Disruptive Behavior? The FTC's Evanston Decision - Are Mergers Still OK? HIPAA and Credentialing HIPAA - Everything You Ever Wanted To Know — And Weren't Afraid to Ask HIPAA Investigations and Enforcement HIPAA Security Regulations Hospitalists: The Who, What and How The "Independent" Medical Staff – What Would It Really Mean? Investigations and Hearings — Should You Follow Your Bylaws? Maybe Not! IRS Final Form 990 The IRS is Watching YOU – Part I: Good Governance Practices for 501(c)(3) Organizations The IRS is Watching YOU – Part II: Exempt Organizations Executive Compensation Compliance Project Report It's Never Too Late for an Amicable Resolution — Alternatives that Can Protect Patients and Save a Career Joint Venture Series The Kadlec Appeal – Decision Against Hospital Reversed! The Limited English Proficiency Rules Low and No Volume Practitioners Malpractice Claims and Your Credentialing Process Malpractice Insurance Premiums: Helping Your Doctors Pay Managing the Disruptive or Difficult Patient Medical Ethical Issues - Right Choices, Legal Answers Medical Record Deficiencies: Practical Solutions to a Persistent Problem Medical Staff Integration Models for a Sustainable Future Medicare Physician Supervision and "Incident-to" Billing: What are the Rules? New MS.1.20: Stay the Course or Jump Ship? Must Hospitals Train Their Staffs to Bite the Hand that Feeds Them? Nonprofit Governance Audio Series: Legal Compliance and Public Disclosure Effective Governance Practices Financial Management and Fundraising On-Call Audit & EMTALA Update On-Call Problems and Solutions The Organized Medical Staff & Joint Commission Compliance:: Real Life Issues, Practical Solutions Panel on Nonprofit Sector Announces Principles for Good Governance and Ethical Practice Patient Complaints and Grievances – Time to Take Them Seriously Patient Safety and Quality Improvement Act: Proposed Regulations Paying for On-Call Services - the OIG Speaks Physician Behavior Physician Recruitment and Retention After Stark III Poliner: Court Upholds Jury's Findings Practical Solutions to Your Toughest On-Call Problems Practical Tips for Developing Medical Staff Leaders Precautionary Suspensions are to Protect Patients A Primer on Preemption: Incorporating State Privacy Laws into Your HIPAA Compliance Plan Protecting Peer Review Information Quality/Performance Improvement & Peer Review Best Practices Reconciling Conflicting Financial Interests of Physicians & Hospitals Recruitment Before Credentialing: What Were You Thinking? Resignation of Privileges to Avoid On Call Responsibilities Self-Disclosure & Government Investigation Sexual Harassment - It's Not Going Away! Does "Sham" Peer Review Really Happen? Sizzlin' Hot Credentialing Issues Specialty Hospitals and Gainsharing Alert! Stark 3.5? Proposed Changes in Inpatient Prospective Payment Rules Stark 2.5 - the Party's Over Stark Phase III Regulations ... They're he-e-e-e-e-e-re! Stark: Software/New Stark and Antikickback Rules Stark Violations in Your Medical Staff Office? Strategies to Address Medical Records Violations Take Control of Your Medical Staff Hearing Process Tax-Exempt Hospitals and Politics: Survival Guide for the Election Year Teleradiologists: Credentialing and Privileging Temporary & Locum Tenens Privileges Unanticipated Outcomes Disclosure and Medical Error Reporting

Credentialing and Medical Staff Records -
Access, Control and Confidentiality Audio CD
Recorded September 13, 2006

Faculty: Alan Steinberg and Monica Hanslovan

What should be included in medical staff committee, department and peer review meeting minutes? More importantly, what shouldn't?
Can a physician review all of the documents in his or her credentials file? Even the most confidential ones?
What information can be provided when outside entities such as government offices (state and federal), accrediting bodies and surveyors request peer review documents? How must those requests be made?
Should any meetings (committees, department, peer review groups) be tape recorded?
Should confidential peer review documents be distributed prior to meetings? If so, how?
What should credentials files include?
Which documents in credentials files should medical staff members be allowed to access? Under what circumstances?
Who should have access to medical staff documents?
How long must credentials files be kept? Can documents in them ever be thrown away?
How can credentials files and peer review documents be shared within a system?

Materials include written guidance regarding the right (and wrong) ways to keep minutes, sample minutes for different kinds of meetings, a distribution letter for the sending of confidential peer review documents, bylaws language for the sharing of credentialing information within a hospital system, a Policy on Confidentiality of Medical Staff Records and a Policy on Medical Staff Member Access to Credentials and Quality Files.

Audio CD: $225

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