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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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