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Retain critical medical staff and hospital documents

Credentialing Resource Center Connection, August 11, 2004

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Dear credentialing colleague:

Medical staff offices often have trouble finding storage space for all their medical staff documents and credentialing files.

However, paperless credentialing and electronic files have allowed some organizations to replace all those manila folders stuffed with important documents with virtual files that are easier to store, locate, and organize. Keep in mind, however, that technology doesn't rewrite all the rules, which means that paper copies of some documents must continue even after the adoption of electronic file systems.

What documents should hospitals keep on file? Think about the records you may need to defend the hospital against legal action. Consult with your legal counsel since retention requirements can vary from state-to-state. Make it the policy of your hospital to retain the following documents for a specified period of time that complies with state law:

1. Nursing policy and procedure manuals
2. Medical staff bylaws
3. Corporate bylaws
4. JCAHO survey reports
5. State survey and inspection reports
6. Other survey reports such as the College of American Pathology, Nuclear Regulatory Commission, insurance carriers, etc.
7. Administrative policy and procedure manual
8. Medical staff credentials files
9. Medical staff executive committee minutes (and possibly other medical staff committees)
10. Performance improvement plans (including plans for invasive procedures review, drug review, and blood review)

File these documents in an appropriate secure location and mark them with the effective dates. Know your state's confidentiality provisions and provide instructions regarding the circumstances in which legal or regulatory authorities may access and review such documents.

That's it for today.

All the best,
Hugh Greeley
www.greeley.com/seminars/

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