Credentialing & Privileging: How do I organize my files?

There are many ways to maintain your credentialing and privileging files. Even if health centers use an electronic/digital tool for organizing their files, most still maintain a paper file as well.

After reviewing hundreds of credentialing and privileging files, we have a few recommendations for how to keep them up-to-date, compliant, and organized.

1. Maintain Separate Files. The ADA requires that “Information from all medical examinations and inquiries must be kept apart from general personnel files as a separate, confidential medical record, available only under limited conditions” (ADA). Specifically related to HRSA credentialing and privileging requirements, we would suggest that clinical staff members’ Fitness For Duty Verification and Immunization & Communicable Disease Verification should be contained in the separate Medical File.

2. Label the sections in order of HRSA requirements. The requirements are listed in the HRSA Site Visit Protocol in a certain order and should be labeled clearly in the same order. Suggested tabs are:

   • Main File

     • Government-Issued Picture ID

     • Education & Training

     • Licensure, Registration, or Certification

     • NPDB Queries

     • DEA Registration

     • BLS Training

     • Current Clinical Competence Verification

     • Other…

   • Medical File

     • Fitness For Duty Verification

     • Immunization & Communicable Disease Verification

     • Other…

3. Develop checklists to make sure files are up-to-date. Especially for health centers who have a large number of clinical staff members, keeping the C/P files current can be quite a task. Use a credentialing and privileging software like RegLantern (Click here to set-up a time to talk about our Credentialing & Privileging Tools) or if you only have a handful of clinical staff, a simple spreadsheet may be enough. Have your C/P manager report-out each month on the documents and files coming due and ensure they have a plan for updating those files. Follow-up and hold them accountable.

4. Review the HRSA Site Visit Protocol at least annually. Regulations (and/or the interpretations and guidance surrounding those regulations) change often. It’s important to stay up-to-date with the current recommendations. Chapter 5 of the SVP is the key chapter that pertains to credentialing and privileging.

5. Train frequently. If you are a RegLantern platform subscriber, check out our Credentialing and Privileging training on RegLantern’s Community Forum. You can also ask questions of our compliance experts or share your best practices. If you are not a RegLantern subscriber, check with your state primary care association (PCA)-they often have valuable training and services available to you (or ask us how you can become a RegLantern continuous HRSA compliance platform subscriber).