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Distinguishing Between Discoverable and Protected Credentialing Material

Analysis  |  By Credentialing Resource Center  
   December 07, 2020

Most states have fairly strong protections, but a handful of states are exceptions to this rule.

A version of this article was first published December 7, 2020, by HCPro's Credentialing Resource Center, a sibling publication to HealthLeaders.

From state to state, the effectiveness of protecting credentials documents from legal discovery varies widely. Most states have fairly strong protections, but a handful of states are exceptions to this rule. In most jurisdictions, credentialing forms, such as the following, are discoverable by attorneys:

  • Delineation of privileges (DOP) templates
  • Application forms
  • Policies and procedures related to credentialing
  • Medical staff bylaws

These are usually considered business documents and may be introduced into court proceedings.

Documents that reflect the actions of peer review bodies are more typically protected from legal discovery
and include the following:

  • Credentialing meeting minutes that reflect deliberations on individual applicants
  • Those parts of an application or credentials file that reflect decisions made by peer review
  • committees
  • References and specific recommendations from a professional peer or body of peers, such as a peer
  • review committee
  • External peer review reports requested by a medical staff peer review committee
  • Many of the communications between the applicant and credentialing-related entities

To determine what can be considered protected in any particular locale, consult with local counsel.

Source: Negligent Credentialing: Strategies for Reducing Hospital Risk

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