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Must a hospital or other health care entity report adverse actions concerning the clinical privileges of medical and dental residents and interns?
The action is not reportable if it was taken within the scope of the training program. Since residents and interns are trainees in graduate health professions education programs, they are not granted clinical privileges per se but are authorized by the sponsoring institution to perform clinical duties and responsibilities within the context of their graduate educational program. However, a resident or intern may practice outside the scope of the formal graduate education program – for example, moonlighting in the intensive care unit or emergency department. Adverse clinical privileges actions related to practice occurring outside the scope of a formal graduate educational program must be reported.