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Continuing Medical Education - Documentation

Are copies of the certificates of attendance at continuing medical education (CME) programs required to be obtained and placed in the credentialing file as proof of attendance?

Any examples are for illustrative purposes only. 

The Medical Staff standards do require that each individuals' participation in continuing education is documented, yet they are not prescriptive about where the files are kept. It will be expected of the organization that the files are retrievable upon request. 

Documentation of attendance can be done in several different ways, including but not limited to:
  • obtaining copies of program certificates,
  • obtaining a copy of the information submitted with a license renewal application when CME's are required by the state, or
  • obtaining an attestation statement from the Licensed Independent Practitioner which attests to his/her attendance at CME programs that relate to their area of practice, with the stipulation that proof of attendance and program content will be submitted upon request.
Last updated on June 22, 2020
Manual: Hospital and Hospital Clinics
Chapter: Medical Staff MS

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