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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).
Last updated on March 16, 2021
Manual: Hospital and Hospital Clinics
Chapter: Medical Staff MS

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