Documentation: Medical Staff Membership (Directions Only)

Although the governance volume is located in the Policy and 
Procedure manual, documentation that surrounds Governance 
should be in its own 3 ring binder.
The Governance Volume was created to as a double check to 
assure that the organization is completing all of its tasks 
surrounding Governance.  
Medical Staff Membership refers to all individuals that are 
credentialed and granted privileges in the organization.
The Governance Manual Table Of Contents in the Governance 
section of the forms repository has directions for setting up 
tabs for the documents which prove you are a business entity; 
i.e., articles of incorporation, partnership agreement, etc. 
This table of contents on the forms repository is meant for 
your separate binder titled Governance.
You can use this area and the other areas (GE.1 through 
GE.16) within this volume to indicate to staff and the 
surveyor where those documents are filed; i.e., Corporate 
Records Book stored in Administrative file, Governance 
Binder, Minutes Binder, Drills Binder etc.  
You may wish to place blank forms that the organization 
utlizes when credentialing and privileging Medical Staff for 
membership in the organization. This area could be the 
repository for every medical staff credentialing form used.  
It is up to you.
This page can be modified without the need of the

consultant's approval.  Once you have read these 
instructions, and made any modifications, you must click the 
accept button.

Approved By Governing Board    
Control #94.0