Run Medical Staff Credentialing File Review — Free

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 critical (required)

Confirm the file contains the minimum required documents for a meaningful review.

Yes No N/A

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 critical (required)

Verify identity documentation is present and matches the provider file.

Yes No N/A

Application form is signed and dated by the provider critical (required)

Confirm the application is complete, signed, and dated.

Yes No N/A

Medical staff bylaws acknowledgment present critical (required)

Confirm acknowledgment or attestation to comply with current medical staff bylaws and rules/regulations.

Yes No N/A

Appointment or reappointment approval documented critical (required)

Verify governing body or delegated committee approval is documented with date and scope.

Yes No N/A

Requested privileges match approved privileges critical (required)

Confirm the file shows a clear match between requested, recommended, and approved privileges.

Yes No N/A

Licensure, Certification, and Registration

Current professional license verified and unexpired critical (required)

Verify active licensure in all applicable jurisdictions and note expiration date.

Yes No N/A

DEA registration present when applicable

Confirm DEA registration is present, current, and consistent with the provider's scope of practice when required.

Yes No N/A

Board certification status documented when required by bylaws or policy

Verify board certification evidence or approved exception is documented.

Yes No N/A

State and federal sanction checks completed within required timeframe critical (required)

Confirm exclusion, sanction, and disciplinary checks were completed per policy and are current.

Yes No N/A

Controlled substance or specialty registrations documented when applicable

Verify any required specialty registrations, prescriptive authority, or controlled substance authorizations are present.

Yes No N/A

Education, Training, and Competency

Medical degree or professional education verified critical (required)

Confirm primary source verification of education is present.

Yes No N/A

Residency, fellowship, or equivalent postgraduate training verified critical (required)

Verify training history aligns with the requested specialty and privileges.

Yes No N/A

Current competency evidence supports requested privileges critical (required)

Review case logs, proctoring, FPPE/OPPE, peer review, or other competency evidence as applicable.

Yes No N/A

Required continuing education or maintenance of certification documented

Confirm continuing education, CME, or maintenance of certification evidence is present when required.

Yes No N/A

Orientation, safety, and mandatory training completed

Verify required hospital orientation, safety, infection prevention, and mandatory training records are current.

Yes No N/A

References, Background Checks, and Professional History

Required peer references are present and acceptable critical (required)

Confirm the number and type of references required by bylaws or policy are present and reviewed.

Yes No N/A

Employment and practice history reviewed for gaps or inconsistencies

Check for unexplained gaps, inconsistencies, or missing chronology in the professional history.

Yes No N/A

Malpractice claims history documented and reviewed

Verify malpractice history, settlements, judgments, and explanations are documented where required.

Yes No N/A

Criminal background check completed when required critical (required)

Confirm background screening is present and current according to policy and applicable law.

Yes No N/A

Privileges, Committee Review, and Final Disposition

Privilege delineation form is complete and signed critical (required)

Confirm requested, reviewed, and approved privileges are clearly documented and signed.

Yes No N/A

Department chair or service chief recommendation documented critical (required)

Verify recommendation is present, dated, and consistent with the file evidence.

Yes No N/A

Credentials committee review documented critical (required)

Confirm committee review, discussion, and recommendation are documented in the file.

Yes No N/A

Governing body or delegated authority final action documented critical (required)

Verify final approval, denial, or conditional approval is documented with effective dates.

Yes No N/A

Any file deficiencies or non-conformances documented with corrective action

Record missing, expired, inconsistent, or late items and the corrective action plan.

Yes No N/A

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Run: Medical Staff Credentialing File Review

Audit Scope and File Identification

Identity, Appointment, and Governance

Licensure, Certification, and Registration

Education, Training, and Competency

References, Background Checks, and Professional History

Privileges, Committee Review, and Final Disposition

Get your results