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Overview Submitting Reports to the NPDB Reporting Medical Malpractice Payments Reporting Adverse Clinical Privileges Actions Reporting Adverse Professional Society Membership Actions Reporting State Licensure and Certification Actions Reporting Federal Licensure and Certification Actions Reporting Peer Review Organization Negative Actions or Findings Reporting Private Accreditation Organization Negative Actions or Findings Reporting Exclusions from Participation in Federal or State Health Care Programs Reporting Federal or State Health Care-Related Criminal Convictions Reporting Health Care-Related Civil Judgments Reporting Other Adjudicated Actions or Decisions

Q&A: Reporting Clinical Privileges Actions

  1. When does the review of an application for reappointment become an investigation if the physician resigns before final action is taken on the reappointment application? For example, if a physician discloses on an application for reappointment that she has been a defendant in three malpractice cases during the last 2 years, and the credentials committee requests additional information about the cases, has an ongoing "routine review" become an "investigation?"

    It depends. A routine or general review is not considered an investigation. So, for example, if all practitioners are automatically or routinely asked for additional information when they are defendants in a certain number of malpractice cases, this type of request probably would not be considered an investigation. Therefore, the resignation would not be reportable. However, if officials at the reappointing hospital had specific concerns about this practitioner's competence based on the number or severity of the medical malpractice cases, then the inquiry appears to deviate from routine review, be focused on a particular practitioner, and concerns competence and conduct issues. In this situation, the activity may be seen as an investigation, and, if so, the resignation would be reportable.

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