Residency

Student and trainee credentialing

Residency Program Insider, December 5, 2006

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Student and trainee credentialing

To comply with accreditation requirements and protect their institutions, program directors and administrators should be aware of credentialing standards that apply to both residents and medical students.

Principles of risk management suggest that all trainees who have patient contact should have some sort of credentials review, specific statements regarding the limits of what they can do, and documented supervision. The hospital may also have employee health requirements, such as tuberculosis testing, that trainees must meet.

Medical students often shadow physicians, but they are not licensed to provide healthcare services, so no privileges should be granted. Students should always function under the direct supervision of a Licensed Independent Practitioner. Hospital or medical staff policies and procedures should address what a student is allowed to do and what documentation from students can be entered into the medical record. Develop these policies in accordance with the state law.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standard HR.1.20 requires the hospital to have a process by which to ensure that a person's qualifications are consistent with his or her responsibilities. This pertains to staff and students as well as volunteers who provide care, treatment, and services. If current licensure, certification, or registration is required, it must be verified. The organization must verify education experience and competency appropriate for assigned responsibilities; information on criminal background (if there is a state law or policy requiring such;) and compliance with applicable health screening requirements established by the organization.

If a student will provide care, treatment, or services-as many do in medical training programs-compliance with this standard is required. Hospital contractual arrangements can require the school to provide documentation required by HR.1.20. According to the JCAHO, a medical student has no legal status as a provider of healthcare services, and the HR chapter standards apply only to direct, contract, and volunteer personnel providing patient care/services. If a student is only observing, the standards do not apply.

All the best,


Kathy Matzka

CPMSM, CPCS
Medical staff credentialing consultant



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