CRITERIA FOR GRANTING MEDICAL PRIVILEGES

Size: px

Start display at page:

Download "CRITERIA FOR GRANTING MEDICAL PRIVILEGES"

Gwendoline Jennings
6 years ago
Views:

1 FOOTHILL PRESBYTERIAN HOSPITAL Glendora, California CRITERIA FOR GRANTING MEDICAL PRIVILEGES Please review these categories carefully to determine those privileges for which you are qualified. Indicate your request below by checking the appropriate category. If you feel that special training or experience qualifies you for advanced privileges, please contact the appropriate department chair. I hereby request Category I, and/or II and/or Category III privileges within the scope of my training and experience. Any licensed physician on staff may render any care in a life threatening emergency. CATEGORY 1: GENERAL The following privileges require board certification or equivalent training in family practice or five years successful practice in family or general practice. Physician may admit, perform history & physicals and treat within their specialty. Consultation strongly suggested for any patient whose diagnosis or management remains in question for more than four days post admission, or for any patient with a life threatening condition. CATEGORY 2: GENERAL ADVANCED The following privileges require board certification or equivalent training or 5 years successful practice in internal medicine. Physician may admit, perform history & physicals and treat within their specialty. Consultation suggested for cases in which diagnosis or management remain in question for a longer than usual period of time. Consultation suggested if patient s condition is life threatening. CATEGORY 3: GENERAL ADVANCED SUBSPECIALTY The following privileges require sub-specialty board certification or equivalent training or 5 years successful practice in this sub-specialty. Physician may admit, perform history & physicals and treat within their specialty. Consultation suggested for cases in which diagnosis or management remain in question for a longer than usual period of time. Consultation suggested if patient s condition is life threatening. PROCTORING REQUIREMENTS: It is the responsibility of the physician doing the procedure to obtain proctor forms and to ensure that the proctoring report is forwarded to the Medical Staff Office. A physician will be removed from the proctoring program when the reports have been reviewed by the Medical Department and the physician is so notified. If, at the time of reappointment, certain procedures have not met the required number to be performed within the past two years, monitoring may be assigned. fph2 2/07

2 Foothill Presbyterian Hospital Medical Privileges Request Form Page 2 After reading the Criteria for Granting Medical Privileges please circle the appropriate Category(s) and return to the Medical Staff Office. DISEASE CLASSIFICATION CATEGORY REQUESTED Allergy/Immunology Cardiology Dermatology Endocrinology Family/General Practice Gastroenterology Hematology Infectious Disease Internal Medicine Neurology Medical Oncology Nephrology Pulmonology Physical/Rehab Medicine Psychiatry Rheumatology Applicants Signature Chair, Medical Department Date Date

3 Name: Appointment: A minimum of three (3) cases of any of the following elective procedures MUST be proctored by a member of the Active Staff who has been granted the privilege. Reappointment: A minimum of three (3) cases of any of the following elective procedures MUST be performed within the past two years. If this is not met, the request will be evaluated and monitoring may be re-assigned. REQUESTED # PERFORMED GENERAL APPROVED DENIED INTERNAL MEDICINE Anoscopy Arterial Puncture EKG Intubation Joint Aspiration Lumbar Puncture Paracentesis Proctoscopy, rigid Sigmoidoscopy Stress Test (Treadmill) Subclavian Catheter Thoracentesis TPN CARDIOLOGY Elective cardioversion Echocardiograph interpretation Holter Monitor interpretation Pericardiocentesis Stress electrocardiogram Subclavian Catheter Right Heart Swan Ganz Atrial CVP Catheter Intra-Arterial Line Arterial Puncture Thrombolytic Therapy Dobutamine/Persantine Stress Test with Nuclear Medicine Carotid Vascular Profile Venous Duplex Scan Extremities Arterial Duplex Scan Extremities (REQUIRES CURRENT FLUOROSCOPY) Pacemaker, temporary transvenous Pacemaker, permanent transvenous DEPARTMENT OF MEDICINE CLINICAL PRIVILEGE CARD PAGE 3

4 Name: DERMATOLOGY Dermatologic Cryotherapy Electrodesiccation/Curettage Excisional Skin Biopsy under local anesthesia Laser for cutaneous lesions (documentation of having taken an approved course in laser therapy must be submitted) Skin Surgery Excision of cancer Facial Non-facial plastic repair Lymph node excision (Region: ) ENDOCRINOLOGY Open/Closed Loop Insulin Infusion Device Thyroid Biopsy GASTROENTEROLOGY Colonscopy Colonscopy with Polypectomy EGD Esophagogastroduodenoscopy ERCP-Endoscopic retrograde cholangiopancreatographywith or without endoscopic papillotomy Esophageal Dilitation - Bouginage - Wire Guided - Pneumatic Flexible Sigmoidscopy with Biopsy with Polypectomy Percutaneous Liver Biopsy Sclerotherapy Band Ligation REQUESTED # PERFORMED HEMATOLOGY/ APPROVED DENIED ONCOLOGY Bone Marrow Aspiration Bone Marrow Biopsy Cancer Chemotherapy DEPARTMENT OF MEDICINE CLINICAL PRIVILEGE CARD PAGE 4

5 Name: NEPHROLOGY Hemodialysis Percutaneous Renal Biopsy Peritoneal Dialysis NEUROLOGY CVP Electroencephalography Electromyography Nerve Conduction Study PSYCHIATRY Psychiatric Evaluation Psychotherapy Detoxification (alcohol or drugs) PULMONOLOGY Arterial Blood Gases Bronchoscopy Bronchoscopy with trans- bronchial biopsy Laryngoscopy Lung Biopsy Mechanical Ventilator Mgmt PFT Pleurodesis Transtracheal Aspiration Tube Thoracotomy (chest tube) Transthoracic Needle Biopsy (Lung or Pleura) Thoracentesis RHEUMATOLOGY Joint Aspiration or Injection Percutaneous Synovial Biopsy REQUESTED # PERFORMED OTHER APPROVED DENIED (Describe fully and provide documentation of training and competence) SIGNATURE OF APPLICANT CHAIR, MEDICAL DEPARTMENT

6 PROCEDURAL SEDATION PRIVILEGES Procedural Sedation: Minimal, Moderate or Deep Sedation (with or without analgesia) for the purpose of performing a diagnostic or therapeutic procedure, for which there is a reasonable expectation that in the manner used, the sedation/analgesia will result in the loss of protective reflexes for a significant percentage or a group of patients. NAME:_ REQUESTED # PERFORMED PROCEDURAL APPROVED DENIED SEDATION (to be marked by Anesthesia Chief) Sedation Analgesia (Requires successful completion of written examination ADULT Meperidine (Demerol) Morphine Diazepam (Valium) Midazolam (Versed) Brevital Sublimaze (Fentanyl) Librium (12 years and older) Ativan Propofol PEDIATRICS Versed Valium Fentanyl Demerol Ketamine SIGNATURE OF APPLICANT ANESTHESIA DIRECTOR Fph4.cspriv.doc2/01, 7/02,4/04,5/05. 5/06

UPMC University of Pittsburgh Medical Center. For Reference Only MEDICINE 2013

UPMC University of Pittsburgh Medical Center. For Reference Only MEDICINE 2013 Summary of Services and Availability (by location) Each location has sufficient space, equipment, staffing and financial resources in place or available in sufficient time as required to support each requested