Q&A: Reporting Clinical Privileges Actions

36. During a hospital's routine chart audit, the hospital discovered that several physicians were "cutting and pasting" notes and/or lab results from one patient's electronic health record (EHR) to another patient's EHR. No patient harm actually occurred, but the hospital viewed these documentation practices as having the potential for patient harm. The hospital took a professional review action against each of the physicians involved, which resulted in the restriction of each of their clinical privileges for 60 days. Should these actions be reported to the NPDB?

    Yes. A clinical privileges action must be reported to the NPDB if it is the result of a professional review action related to professional competence or conduct that adversely affects, or could adversely affect, the health or welfare of a patient and lasts for a period longer than 30 days. Whether an action affects or could affect patient health or welfare generally is a determination that must be made by the entity taking the action. In this case, the hospital viewed the documentation practices as having the potential for patient harm, so the restrictions must be reported.