J-9_Document_Checklist.pdf

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Medical Staffing Services
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HSCEDM-16-R-0002
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J-9 Document Checklist

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J‐9 ‐ DOCUMENT CHECKLIST

Personnel Documents

Document Title Credentialing Documents

Privileged (LIP)

Privileging Documents

Ad m in is tr at iv e As si st an t

M ed ic al R ec or ds T ec h

N ur se P ra ct iti on er s

Ph ys ic ia n As si st an t

Re gi st er ed

N ur se s

LV

N L

PN

C M A C.

N .A

Ra di ol og y Te ch ni ci an

Ph ar m ac is t

Ph ar m ac y Te ch ni ci an

D en ta l A ss is ta nt

D en ta l H yg ie ni st

Al l P hy si ci an s

Ps yc hi at ris t

Ps yc ho lo gi st

D en tis t

So ci al W or ke r

Section I ‐ Privileges Application for Privileges X X X X X IHSC Privilege Letter X X X X X Peer Review X X X X X X X X X Statement of Health and Ability X X X X X X X X X X X X X X X X Statement of Confidentiality X X X X X X X X X X X X X X X X Ackn of Policy Understanding (local, national, residential standards) X X X X X X X X X X X X X X X X Statement of Risk and Responsibility X X X X X X X X X X X X X X X X Malpractice Insurance X X X X X X X X X X X X X X Release of Information X X X X X X X X X X X X X X X X

Section II ‐ Education Professional School Diploma (primary source verified) X X X X X X X X X X X X X X Internship / Residency Documents/Preceptor Documents X X Professional License / Certification (primary source verified) X X X X X X X X X X X X X X Board Certification X X X X National Practitioner Database X X X X X AHA Heartsaver® CPR AED or BLS for Healthcare Providers® Certification X X X X X X X X X X X X X X X X

Section III ‐ Experience and Current Competency HSD‐500 Facility Orientation Checklist X X X X X X X X X X X X X X X X Scope of Practice X X X X X X X X Competency Checklist X X X X X X X X X X X

Section IV ‐ Professional Information Position Description (signed) X X X X X X X X X X X X X X X X Evaluations X X X X X X X X X X X X X X X X CV/Resume X X X X X X X X X X X X X X X X Personnel Actions (Awards/Letters of Appreciation/Letters of Counseling) X X X X X X X X X X X X X X X X Emergency Contact X X X X X X X X X X X X X X X X

1 of 6 HSCEDM‐16‐R‐00002

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