to main content Credentialing and Privileging - Consultants | Hospital and Hospital Clinics | Medical Staff MS | The Joint Commission
Credentialing and Privileging - Consultants

Does The Joint Commission require licensed practitioners (LP) 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 LP who was asked to evaluate a patient and provide consultation, by way of an order from another LP.  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).
Manual: Hospital and Hospital Clinics
Chapter: Medical Staff MS
Last reviewed by Standards Interpretation: February 04, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: December 30, 2016 This Standards FAQ was first published on this date.
This page was last updated on November 17, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
Was this response helpful?

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form

Get Extra Help with Books and E-books

Browse our gallery of books and e-books to find trusted prep and readiness resources, practical checklists and toolkits, and resources on specialized health care topics.

Stay Informed with Online Education

Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization.

Reach Your Safety Goals with eProducts

Assessing and sustaining compliance with accreditation standards or CMS CoPs can be a challenge, but it doesn’t have to be. Rely on our proven software solutions developed by our team of industry experts.

Can't Find What You're Looking For?

If you do not find an answer to your question, please contact the Standards Interpretation Group (SIG).

Note: To provide adequate support to those organizations that are either accredited/certified or seeking accreditation/certification, we will only answer those questions submitted by those organizations seeking accreditation/certification or currently accredited/certified by the Joint Commission. The Joint Commission no longer answers questions submitted by students or vendors. Thank you for your understanding.