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Credentialing and Privileging - Consultants

Does The Joint Commission require licensed independent practitioners (LIP) that provide consultative services to be credentialed or privileged?

Any examples are for illustrative purposes only.

Yes, consultants that evaluate patients and recommend care, treatment, or services are required to be credentialed and privileged. Compliance with the organization's process for monitoring a practitioner's professional performance, clinical/technical skills, etc. is also required.

The Joint Commission describes a consultant as a LIP who was asked to evaluate a patient and provide consultation, by way of an order from another LIP.  The consultant's findings are entered into the medical record and may be used by other practitioners to determine the ongoing course of care, treatment, or services.

Additionally, the requirements found at RC.02.01.01 EP 2 require that the medical record contain documentation of any consultation reports. Therefore, organizations need to ensure that consultants have been identified as authorized to make entries into the medical record (see RC.01.02.01 EP 1).
Manual: Behavioral Health
Chapter: Human Resources Management HRM
Last reviewed by Standards Interpretation: February 04, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: December 30, 2016 This Standards FAQ was first published on this date.
This page was last updated on February 04, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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