Scanning of Inactive

Physician Credentials
Presented by
Anjali Singh

Goal Statement
The

goal of the project is to identify the

clinically inactive physician as one who is not
engaged in direct, consultative or supervisory
patient care at the time of licensure renewal
or not with the hospital for any reason.

List of Resources
List

of resources used in the project:

LTAC

Software
Facility Site Director Ms. Tracy Barker
Ms. Janica Shaw
ImageNow Imaging System

List of Resources continued

Discrepancies between what was provided by
the applicant and what was discovered during
the verification process.
Resignations from previous medical staff
positions.
Involuntary termination of medical staff
membership and involuntary changes or denials
of clinical privileges at another organization or
organizations

List of Resources continued

Disciplinary

actions during residency or

fellowship programs and/or by previous
healthcare organizations, state medical
licensure boards, or professional
organizations.
Gaps in professional residency or fellowship
training or practice history
Inability to hold Drug Enforcement
Administration (DEA) registration

List of Resources continued

Employment and professional practice issues during

previous work engagements.
Formal investigations by state medical licensing and
medical staff review boards, which may or may not
include sanctions.
Formal investigations pertaining to fraud, abuse, antikickback, Centers for Medicare & Medicaid (CMS)
Services requirements, and other federal healthcare
compliance laws and regulations that may or may not
include sanctions

List of Resources continued

Inability

to verify professional liability

insurance coverage
Gaps in professional liability insurance
coverage
History of jury verdicts and settlements of
professional liability claims
HP Scanner

Project Scope

The quality and safety of patients is dependent upon the strength of

an organizations leadership and accountabilityas well as the
strength and integrity of its institutional programs and processes.

Having a sound physician credentialing program and process in

place that is appropriately hardwired and consistently followed is a
key element in meeting the high standards todays consumers have
regarding healthcare organizations. The scope of the project is that
upon practitioner resignation or termination, the existing
credentialing file is scanned into the ImageNow imaging system
creating a paperless and electronic credentialing file.

Tasks
The

tasks of the project are as follows:

Upon practitioner resignation or termination, the existing

credentialing file is scanned into the lmageNow imaging system
creating a paperless and electronic credentialing file. The file may
be referenced in the future by accessing the documents in
ImageNow. The paper file is retained for a specified time period and
then placed for destruction with a company approved secure
shredding service. Please review credentialing policy CR-706.

The following will provide steps to scanning an inactive credentialing

file to lmageNow :

Task. Continued.

Verify the practitioner has been updated to inactive in the

MEDHOST system.
Prepare the credentialing file for scanning.
In MEDHOST go to UtilitiesCredentialing Physician Master File
Inquiry. Enter the practitioners MEDHOST Physician number or click
on F4 to select the practitioner from a list. The screen below is a
blank version of the screen you will need to be on to scan inactive
files .
*The practitioner must be marked as INACTIVE next to the
hospital status code field prior to scanning an inactive
credentialing file.

Task. Continued.

Task. Continued.

Task. Continued.

Task. Continued.
Open

and log into lmageNow. At the Basket

Group Selection, check the eCredentialing
Doc
When scanning inactive files, only use the
document types under the eCredentialing
basket group. Scan the entire credentialing
paper file as one packet to the document
type, "Inactive File".

List of Deliverables
For

assembly of medical records

To assure easy access to patient information by standardizing the

order in which the medical record is assembled at discharge. A
medical record must be maintained for every individual evaluated or
treated in the hospital. Medical records must be accurately written,
promptly completed, properly filed and retained, and accessible.
Procedure: Each discharged chart is delivered to the Health
Information Department daily.
Health Information Management Personnel assure that all medical
records are accounted for every patient discharge.

Task. Continued.

Shred all nursing Kardex and copies of originals.

Check to ensure patients name and unit number are on every form.
Insert any loose reports (lab slips etc.) in chart.
Assemble record according to established chart assembly order.
Medical record section dividers/tabs should be recycled and reused
after the record has been completed. Tabs should remain in chart
from admission through discharge and completion of the record.
However, section dividers/tabs do not need to stay in the medical
record permanently.
Analyze the discharge record.

List of Deliverables
Electronic

Signatures:

The use of electronic signatures in medical record documentation is

an approved method for hospital physicians and staff to authenticate
dictated reports.
Policy: Before applying an electronic signature, practitioners are
required to review their entries for completeness and accuracy,
correcting or modifying them as needed.
The user must carefully protect their computer password to ensure
that only authorized individual can use it.
Each practitioner using electronic signatures will sign and date a
statement that he/she alone is the only person who has access to
and who will use his/her signature electronically.

List of Deliverables
Health

Information staff will maintain a list of

physicians or other healthcare practitioners
who are authorized to use electronic
signatures and who have signed the
electronic signatures acknowledgment.

List of Deliverables
ImageNow

Online Record Storage:

Records retrieved in electronic form from offsite

storage will be retained electronically in the
imaging system. When requesting records from
Iron Mountain using image on Demand records will
be temporarily placed on L Drive. Records will then
be transferred to ImageNow for permanent storage
and removed from L Drive.

Risks
The

risk of the project includes:

Records need to be filed in accordance with a standard facility

archival system to ensure the prompt location of a physician's
record.
Safeguards exist to prevent unauthorized access; the information
contained in the inactive physicians records is confidential and is
not to be released without legal authorization. Facilities participating
in the project will be required to maintain detailed medical and social
records of inactive physicians.
Inactive physicians record shall not be removed from the facility,
except for shredding unless expressly and specifically authorized by
the Department.

Timeline
The

timeline of the project is as follows:

Practicum site selection on October 25th, 2016.

Contacted Ms. Barker via phone on October 25th, 2016.
Practicum site confirmation via email with site director Ms. Tracy
Barker on October 28th, 2016.
Received site supervisor Ms. Janicas contact information via email
on October 28th
Reached at facility on October 31st, 2016.
Met with Ms. Barker, site director and Ms. Janica to learn the
process.
On November 11th, I mentored Ms. Nicole Howard to scan active
physicians credential MEDHOST system.