Medical Staff Credentialing File Review

File-by-file audit of medical staff credentialing elements against medical staff bylaws, CMS Conditions of Participation, and internal credentialing policy requirements.

Audit Scope and File Identification

• Provider file identified with full name, role, and unique credentialing identifier
  Record the provider's full legal name, credentialing file ID, specialty or role, and review period.
• Review type confirmed
  Select the type of file review being performed.
• File is complete enough to evaluate against bylaws and policy
  Confirm the file contains the minimum required documents for a meaningful review.
• Review date documented
  Enter the date and time the file review was completed.
• Reviewer name and credentials documented
  Enter the reviewer name, title, and department or committee affiliation.

Identity, Appointment, and Governance

• Government-issued identity verification present
  Verify identity documentation is present and matches the provider file.
• Application form is signed and dated by the provider
  Confirm the application is complete, signed, and dated.
• Medical staff bylaws acknowledgment present
  Confirm acknowledgment or attestation to comply with current medical staff bylaws and rules/regulations.
• Appointment or reappointment approval documented
  Verify governing body or delegated committee approval is documented with date and scope.
• Requested privileges match approved privileges
  Confirm the file shows a clear match between requested, recommended, and approved privileges.

Licensure, Certification, and Registration

• Current professional license verified and unexpired
  Verify active licensure in all applicable jurisdictions and note expiration date.
• DEA registration present when applicable
  Confirm DEA registration is present, current, and consistent with the provider's scope of practice when required.
• Board certification status documented when required by bylaws or policy
  Verify board certification evidence or approved exception is documented.
• State and federal sanction checks completed within required timeframe
  Confirm exclusion, sanction, and disciplinary checks were completed per policy and are current.
• Controlled substance or specialty registrations documented when applicable
  Verify any required specialty registrations, prescriptive authority, or controlled substance authorizations are present.

Education, Training, and Competency

• Medical degree or professional education verified
  Confirm primary source verification of education is present.
• Residency, fellowship, or equivalent postgraduate training verified
  Verify training history aligns with the requested specialty and privileges.
• Current competency evidence supports requested privileges
  Review case logs, proctoring, FPPE/OPPE, peer review, or other competency evidence as applicable.
• Required continuing education or maintenance of certification documented
  Confirm continuing education, CME, or maintenance of certification evidence is present when required.
• Orientation, safety, and mandatory training completed
  Verify required hospital orientation, safety, infection prevention, and mandatory training records are current.

References, Background Checks, and Professional History

• Required peer references are present and acceptable
  Confirm the number and type of references required by bylaws or policy are present and reviewed.
• Employment and practice history reviewed for gaps or inconsistencies
  Check for unexplained gaps, inconsistencies, or missing chronology in the professional history.
• Malpractice claims history documented and reviewed
  Verify malpractice history, settlements, judgments, and explanations are documented where required.
• Criminal background check completed when required
  Confirm background screening is present and current according to policy and applicable law.

Privileges, Committee Review, and Final Disposition

• Privilege delineation form is complete and signed
  Confirm requested, reviewed, and approved privileges are clearly documented and signed.
• Department chair or service chief recommendation documented
  Verify recommendation is present, dated, and consistent with the file evidence.
• Credentials committee review documented
  Confirm committee review, discussion, and recommendation are documented in the file.
• Governing body or delegated authority final action documented
  Verify final approval, denial, or conditional approval is documented with effective dates.
• Any file deficiencies or non-conformances documented with corrective action
  Record missing, expired, inconsistent, or late items and the corrective action plan.