PRIVILEGE APPLICATION FORM - [Mercy Medical Center]

Transcription

1 Current Privilege Status Key Practitioner's Current Privilege status is signified in ( ) preceding each privilege. G = W = Withdrawn T = Temporary P = With Proctor A = Assist with C = With Consult E = Emergency Only RQ = L = Leave of Absence R = Resigned S = Suspended Staff Category - Associate Staff ( ) ASSOCIATE MEDICAL STAFF: The associate Medical Staff shall consist of physicians, dentists and podiatrists who are being considered for advancement to membership as active or courtesy members of the Medical Staff. They shall be appointed to a specific department and may be appointed to serve on committees. They shall be ineligible to hold office in this Medical Staff organization. However, candidates for active staff status shall have voting privileges and shall accept emergency department coverage assignments. All associate Medical Staff memberships shall be provisional for a period of one year. Associate membership renewal may not exceed an additional year, following which the failure to advance from associate Medical Staff membership shall be deemed a termination of Medical Staff membership. An associate Medical Staff member whose membership is so terminated shall have hearing rights accorded by the Medical Staff bylaws if the termination is an Adverse Action as defined in the Medical Staff bylaws. Associate Medical Staff members shall be assigned to a department where their performance shall be evaluated by the chairperson of the department or the chairperson's representative in order to determine the eligibility of such associate staff members for continued Medical Staff membership and for exercising the clinical privileges provisionally granted to them. Staff Category - Active Staff ( ) ACTIVE MEDICAL STAFF: The active Medical Staff shall consist of physicians, dentists and podiatrists who regularly admit patients and/or provide services in the hospital, who are able to comply with response times set by their departments and otherwise provide continuous care to their patients, and who assume all the functions and responsibilities of membership on the active Medical Staff including emergency department coverage and consultation assignment as determined by the medical staff emergency department plan which is approved by the Medical Executive Committee. Members of the active Medical Staff shall be appointed to a specific department, shall be eligible to vote, to hold office, and to serve on Medical Staff committees. Page 1 of 12

2 Staff Category - Affiliate Staff ( ) AFFILIATE MEDICAL STAFF: The affiliate Medical Staff shall consist of physicians, podiatrists and dentists who wish to be associated with Mercy Medical Center and its Medical Staff but have little or no active practice in the hospital. Members of the affiliate Medical Staff shall be appointed to a specific department of the Medical Staff, shall be eligible to vote, and shall be eligible to serve on Medical Staff committees. They shall be ineligible to hold office in this Medical Staff organization. Affiliate Medical Staff members shall not have clinical privileges or provide orders on inpatients. Affiliate Medical Staff members wishing to refer a patient for inpatient care shall be responsible for arranging, at the time of admission, for the overall medical responsibility for the patient's care in the hospital to be assumed by a Medical Staff member of the appropriate specialty who holds full admitting privileges. Staff Category - Courtesy Staff ( ) COURTESY MEDICAL STAFF: The courtesy Medical Staff shall consist of physicians, dentists and podiatrists qualified for Medical Staff membership but who only occasionally attend patients in the hospital. Courtesy Medical Staff membership is limited to those individuals who bring a unique skill to the community, or serve only occasionally as consultants in the hospital. Telemedicine members will be members of the courtesy Medical Staff. Courtesy Medical Staff members shall be appointed to a specific department. They shall be ineligible to vote or hold office in this Medical Staff organization and shall not be required to provide emergency department coverage. Signed: Dated: ** The affiliate physician does not have privileges for inpatient care. If Affiliate checked, do not complete the rest of this form. ** Date: 1985 Revised: Dec 1989, Mar 1998, Dec 2010 Department of Surgery Page 2 of 12

3 Skin, Subcutaneous, Areolar Tissues ( ) Hyperbaric oxygen therapy for wound care in Wound Healing Center * ( ) Wound treatment in Wound Healing Center * ( ) I&D or resection, sebaceous cysts ( ) I&D or resection, furuncle ( ) I&D or resection, carbuncle ( ) I&D or resection, pilonidal cysts ( ) I&D or resection, hidradentis suppurative ( ) I&D or resection, hematoma ( ) I&D or resection, other skin lesions, benign or malignant ( ) Removal of foreign body ( ) Biopsy, skin, subcutaneous tissue, mucous membrane ( ) Excision, nail and/or nail matrix ( ) Injection, sclerosing solution, not including injection of esophageal varices. ( ) Repair of wounds, small or large, including debridement and skin grafting ( ) Treatment of burns, including resuscitation, dressing changes, skin grafting ( ) Electro-surgical destruction, benign, malignant lesions ( ) Chemocautery or cryotherapy (CO2, liquid nitrogen) Page 3 of 12

4 Breast ( ) Stereotactic breast biopsy * ( ) Aspiration of cyst ( ) Mastotomy or drainage of abscess ( ) Incisional/excisional biopsy of benign/malignant lesions ( ) Breast ultrasonography ** ( ) Mastectomy, with or without skin grafting, simple or total ( ) Mastectomy, with or without skin grafting, partial or segmental ( ) Mastectomy, with or without skin grafting, modified or radical ( ) Mastectomy, with or without skin grafting, excision of chest wall, including ribs ( ) Removal of I-125 Brachytherapy Seeds for Breast Lesion Localization Studies * **Breast ultrasonography certified by the American Society of Breast Surgeons and performed by an American Board of Surgery certified General Surgeon is indicated for identification and characterization of focal breast abnormalities, guidance of diagnostic, invasive, and therapeutic procedures in the breast(s) and axilla, and assessment or evaluation of abnormalities during and after medical or surgical therapy. Bone ( ) Open or closed biopsy ( ) Excision, for exposure, treatment or decompression ( ) Insertion or removal of wire, pin or tongs ( ) Fractures of sacrum ( ) Fractures of coccyx ( ) Fractures of clavicle ( ) Fractures of pelvis ( ) Fractures of ribs ( ) Fractures of sternum ( ) Fractures of scapula ( ) Fractures of phalanx ( ) Arthrocentesis for aspiration or injection of medication ( ) Excision ganglion, bursa and neuroma Page 4 of 12

5 Muscles ( ) Removal of foreign body ( ) Division of anterior scalene, with or without resection of cervical/first rib ( ) Biopsy ( ) Division of sternomastoid for torticollis or exposure for associated operations ( ) Repair of ruptured/herniated diaphragm, transabdominal or thoracic ( ) Fasciotomy, upper extremities ( ) Fasciotomy, lower extremities Amputation ( ) Upper extremity, interscapulothoracic, transhumeral ( ) Lower extremity, digital or ray ( ) Lower extremity, transmetatarsal or syme ( ) Lower extremity, below the knee ( ) Lower extremity, above the knee ( ) Lower extremity, disarticulation Respiratory System ( ) Laryngoscopy, direct or indirect, with or without biopsy ( ) Bronchoscopy, with or without biopsy ( ) Removal of foreign body ( ) Thoracotomy (please note that pneumonectomy or lobectomy require American Board of Thoracic Surgery certification or eligibility) ( ) Tracheostomy ( ) Tracheal aspiration or injection of medication Page 5 of 12

6 Vascular System ( ) Arterial or venous embolectomy or thrombectomy ( ) Major arterial reconstruction for occlusive or aneurysmal disease ( ) Creation or revision of arterio-venous fistula ( ) Arteriography or intra-arterial injections - intraoperative, operative, emergency ( ) Venous ligation, excision or stripping ( ) Exposure of or incision into vein or artery for angio access/monitoring ( ) Cervicocerebral arteriography * (specific privilege criteria apply) ( ) Carotid interventions * (specific privilege criteria apply) Lymphatic System ( ) Splenectomy ( ) Splenorrhaphy, splenic salvage or repair ( ) Incision and drainage of lymphatic abscess ( ) Biopsy, excision of lymph node ( ) Lymphadenectomy, cervical (including radical neck dissection) ( ) Lymphadenectomy, axilla, groin, superficial or deep ( ) Lymphadenectomy, paraaortic or pelvic dissection Lips, Tongue ( ) Excision of benign or malignant lesions, lips ( ) Biopsy of tongue lesion or suture of tongue wound or injury Page 6 of 12

7 Esophagus ( ) Biopsy of oropharynx ( ) Excision of pharyngoesophageal (Zenker's) diverticulum ( ) Excision of brachial cleft cyst or vestige ( ) Esophagotomy, cervical or thoracic ( ) Esophagogastrectomy ( ) Esophagoduodenostomy ( ) Esophagomyotomy (Heller type) ( ) Esophagostomy, fistualization of esophagus, external ( ) Direct ligation of esophageal varices ( ) Suture of esophageal wound, injury or rupture, cervical/thoracic ( ) Dilatation of esophagus, initial or subsequent ( ) Esophagotomy, resection ( ) Esophagus, excision of diverticulum, limited to neck Stomach ( ) Esophagogastroduodenoscopy with or without biopsy ( ) Gastrotomy or gastrostomy ( ) Pyloromyotomy (Fredet - Ramstedt) ( ) Biopsy of stomach by endoscopy or laparotomy ( ) Gastrectomy, with or without vagotomy, partial ( ) Gastrectomy, with or without vagotomy, total ( ) Vagotomy, transabdominal or transthoracic ( ) Esophagoduodenostomy or esphagojejunostomy following gastrectomy ( ) Gastrorrhaphy, suture perforated gastric or duodenal ulcer/injury ( ) Closure of gastrostomy ( ) Gastric operation for morbid obesity * Page 7 of 12

8 Intestines ( ) Enterotomy with exploration, biopsy, removal of foreign body - large bowel ( ) Enterotomy with exploration, biopsy, removal of foreign body - small bowel ( ) Exteriorization of intestine, jejunostomy, ileostomy, colostomy ( ) Reduction of volvulus, intussusception or internal hernia ( ) Reduction of small or large bowel ( ) Colectomy, partial or total, with colostomy or ileostomy ( ) Adhesiotomy; freeing of intestinal adhesions ( ) Cecopexy, sigmoidopexy or gastropexy ( ) Excision of Meckels diverticulum ( ) Appendectomy ( ) Mesentery, suture or repair of injury ( ) Excision of lesion of mesentery ( ) Transabdominal or transrectal drainage of appendiceal abscess Rectum ( ) Abdominal perineal resection or complete proctectomy ( ) Drainage of perirectal, supralevator, pelvic or retrorectal abscess ( ) Repair of rectal procidentia ( ) Local excision of extensive villous papilloma or villous adenoma of the rectum, with sphincter saving approaches or procedures. ( ) Lower anterior resection ( ) Proctoplasty for stenosis or prolapse of mucous membrane ( ) Proctectomy for congenital megacolon with reconstruction Anus ( ) Colonoscopy, including pancolonoscopy, with biopsy or polypectomy * ( ) Endoscopy, anal ( ) Enucleation or excision of thrombosed external hemorrhoid ( ) Fistulotomy or fistulectomy ( ) Hemorrhoidectomy, internal or external ( ) Hemorrhoidal ligation or banding ( ) Proctosigmoidoscopy ( ) Sphincterotomy Page 8 of 12

9 Liver ( ) Aspiration or needle biopsy of liver ( ) Hepatectomy, partial ( ) Hepatorrhaphy, suture of wound or injury, including drainage ( ) Drainage of liver abscess Biliary Tract ( ) Cholecystectomy or cholecystotomy ( ) Cholecystoenterostomy ( ) Choledochoscopy, flexible or rigid, including biopsy ( ) Choledochotomy for removal, exploration, drainage or calculus with or without cholecystectomy ( ) Transduodenal sphincteroplasty Pancreas ( ) Abdominal drainage and exploration of pancreatitis ( ) Biopsy, including transduodenal needle biopsy ( ) Marsupialization, pancreatic pseudocyst, internal anastamosis ( ) Pancreatectomy, subtotal and total ( ) Pancreatico-jejunostomy ( ) Radical pancreatico-duodenectomy (Whipple procedure) Abdomen, Peritoneum, Omentum ( ) Excision intra-abdominal or retroperitoneal tumor ( ) Exploratory laparotomy ( ) Insertion of peritoneal dialysis catheters ( ) Insertion peritoneo-venous fistulas or tubing ( ) Omentectomy, partial or complete ( ) Paracentesis ( ) Laparoscopy Page 9 of 12

10 Hernia ( ) Repair of dehiscence or evisceration ( ) Suture of abdominal wall defect including pediatric abdominal wall defects, i.e., gastroschisis or omphalocele ( ) Unilateral or bilateral - diaphragmatic ( ) Unilateral or bilateral - epigastric ( ) Unilateral or bilateral - femoral ( ) Unilateral or bilateral - inguinal ( ) Unilateral or bilateral - internal ( ) Unilateral or bilateral - umbilical ( ) Ventral, incisional - congenital ( ) Ventral, incisional - acquired ( ) Ventral, incisional - traumatic Kidney ( ) Division, transection or revascularization of aberrant renal vessels ( ) Nephrectomy, including partial ureterectomy ( ) Ureterplasty or ureterorrhaphy Urogenital ( ) Closure of vesico-vaginal, colo-vesicle fistulas ( ) Introduction of foley catheter ( ) Partial cystectomy, in conjunction with associated fistula or tumor, i.e., colovesical fistula or invasive colon carcinoma invading bladder ( ) Repair of hydrocele and/or inguinal hernia ( ) Repair or ligation of varicocele ( ) Testicle, orchiectomy or orchiopexy Page 10 of 12

11 Female Genital ( ) Biopsy of vagina ( ) Biopsy of vulva ( ) Colpoperineoplasty, posterior vaginal wall, repair of rectocele and perineoplasty, pelvic floor repair ( ) Colpotomy with exploration or drainage of pelvic abscess ( ) Excision of benign lesion of vagina ( ) Excision of vaginal septum ( ) Incision and drainage of Bartholin's gland abscess ( ) Oviduct, excision of ( ) Oviduct, salpingectomy, complete or partial, unilateral or bilateral ( ) Salpingo-oophorectomy, complete or partial, unilateral or bilateral ( ) Puncture and aspiration of cul de sac ( ) Repair of rectocele ( ) Biopsy of cervix or endometrium ( ) Closure of perineal, recto-vaginal, vesico-vaginal fistula ( ) Total hysterectomy, with or without tubes and/or ovaries ( ) Repair of cystocele, rectocele, uterine prolapse Endocrine ( ) Adrenalectomy, unilateral or bilateral, for benign or malignant disease ( ) Carotid body tumors, excision of tumor, with or without segmental arterial resection or intraposition graft ( ) Parathyroidectomy or exploration ( ) Parathyroid transplantation ( ) Aspiration of thyroid cyst ( ) Excision of thyroglossal duct, cyst or sinus ( ) Thyroidectomy, lobectomy ( ) Thyroidectomy, subtotal ( ) Thyroidectomy, total ( ) Associated neck dissection with thyroid operations Anesthesia ( ) Moderate (conscious) sedation * Page 11 of 12

12 Long Term Care ( ) Admit, diagnose, provide ongoing care to patients, within the limitations, staffing and equipment of the setting. Additional General Surgery Privileges ( ) Mechanical ventilation* ( ) Laparoscopic cholecystectomy ( ) Laser surgical procedures ( ) Computer-enhanced laparoscopic procedures* Signature I have requested and will exercise only those privileges for which by education, training, current experience, and demonstrated performance, I am qualified to perform. Signed: Date: * specific privilege criteria or requires evidence of education and experience Page 12 of 12