Date
of Last Review 5/7/07
SME: Director of Personnel Systems Management
Personnel files are under the maintenance and supervision of Personnel Systems
Management (PSM) to ensure security and compliance with JCAHO standards.
The Hospital-Wide Education department, Human Resources and the departmental manager furnish the following documents needed for the PSM check-in process:
 | Copy of application |
| NEO checklist |
| Departmental orientation checklist |
| Initial assessment of competency checklist |
| Licensure, certification or registration verification documentation (if required for position) |
|
Degree verification |
|
Reference check |
| Signed copy of the competency-based job description |
The following are duties performed by Personnel Systems staff for new hires:
| Complete a check off list to ensure all required documents are received. |
| Place any incomplete personnel file in a pending mode until the file is complete. |
| Prepare all personnel files with appropriate tags identifying required JCAHO documents to ensure 365-day preparedness. |
The following are policies regarding review of personnel files:
| Only managers/supervisor or administrators at UTHCPC are allowed to access personnel files |
| Managers/supervisors are limited to review of only files belonging to their staff. |
| Exceptions of any kind must be requested to the manager of Personnel Systems and approved in advance |
| Files must remain in PSM unless the manager/supervisor or administrator checks out the file |
| Employees requesting to review their personnel file must make their request in writing to their supervisor. |
The following is the process for reviewing personnel files:
Step |
Action |
1 |
During the hours of 8-5, contact PSM staff for file requests. |
2 |
Requestor fills out the personnel file review log in PSM when requesting personnel files to be pulled for review. |
3 |
PSM staff place a check-out card in the spot where the personnel file resides indicating the file is checked out and to whom it is checked out. |
4 |
Requestor reviews file in the PSM department unless she/he chooses to check out the file. |
The Joint Commission Human Resources Standards
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
