April Grand Rounds – Back to the Basics: 
Documenting Progressive Steps and Other 
Credentialing and Peer Review Activities 
April 4, 2023 - 1:00 pm to 2:00 pm (ET) 
Almost all Medical Staff leaders will, at some point, be called on to engage in credentialing 
and/or peer review of a colleague, whether it’s a collegial, mentoring meeting or, at the more 
extreme side of things, an MEC meeting where adverse action is on the table. So, it’s important 
that all physician leaders understand when and how to document credentialing and peer review 
activities – and also appreciate the difference in tone and treatment when generating 
documentation relating to early collegial efforts versus that involving more formal professional 
review activities. 
Topics: 
 The pros and cons of creating written documentation of Medical Staff activities 
 The importance of tone in all professional review communications 
 Documenting requests for clarification of suspected misrepresentations and/or omissions 
on applications 
 Notifying a practitioner of an incomplete application 
 Notification of application withdrawal 
 Requests for information from Medical Staff members 
 Invitations to meet 
 Mandatory meeting notifications/invitations 
 Drafting a follow-up letter to an initial mentoring effort or a collegial intervention 
meeting 
 What goes in a written Performance Improvement Plan? 
 Documentation of a Medical Staff investigation 
 Adequate notice when the MEC is considering denial or revocation 
 Documentation of an adverse recommendation by the MEC 
 What goes in a notice of adverse recommendation/ notice of right to a hearing?