UNM SRMC SLEEP MEDICINE CLINICAL PRIVILEGES.

Transcription

1 Initial privileges (initial appintment) Renewal f privileges (reappintment) Expansin f privileges (mdificatin) INSTRUCTIONS All new applicants must meet the fllwing requirements as apprved by the UNM SRMC Bard f Directrs effective: 08/21/2013 Applicant: Check ff the "Requested" bx fr each privilege requested Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current cmpetence, current clinical activity, and ther qualificatins, and fr reslving any dubts related t qualificatins fr requested privileges Clinical Service Chief: Check the apprpriate bx fr recmmendatin n the last page f this frm If recmmended with cnditins r nt recmmended, prvide cnditin r explanatin n the last page f this frm Other requirements: 1) Nte that privileges granted may be exercised nly at and in setting(s) that have the apprpriate equipment, license, beds, staff, and ther supprt required t prvide the services defined in this dcument Site-specific services may be defined in hspital r department plicy 2) This dcument is fcused n defining qualificatins related t cmpetency t exercise clinical privileges The applicant must als adhere t any additinal rganizatinal, regulatry, r accreditatin requirements that the rganizatin is bligated t meet Practice Area Cde: SRMC-Sleep Versin Cde: a Page: 1

2 Qualificatins fr Sleep Medicine T be eligible t apply fr cre privileges in sleep medicine, the applicant must meet the fllwing criteria: Successful cmpletin f an American Academy f Sleep Medicine (AASM) r Accreditatin Cuncil fr Graduate Medical Educatin accredited fellwship prgram in sleep medicine AND/OR Current specialty certificatin in Anesthesilgy, Internal Medicine, Family Medicine, Neurlgy, Otlarynglgy, r Psychiatry by the relevant American Bard f Medical Specialties r by the relevant American Ostepathic Bard AND/OR Current subspecialty certificatin r active participatin in the examinatin prcess with achievement f certificatin within 3 years leading t subspecialty certificatin in sleep medicine by the relevant American Bard f Medical Specialties r cmpletin f a certificate f added qualificatins by the relevant American Ostepathic Bard OR Current certificatin by the AASM is acceptable fr applicants wh became certified prir t 2007 AND Required previus experience: Applicants must be able t demnstrate prvisin f care reflective f scpe f privileges requested, in the last 24 mnths r demnstrate successful cmpletin f an ACGME- r AOA-accredited residency, clinical fellwship, r research in a clinical setting within the past 12 mnths Reappintment requirements: T be eligible t renew cre privileges in sleep medicine, the applicant must meet the fllwing maintenance f privilege criteria: Current demnstrated cmpetence and an adequate vlume f experience (inpatient, Practice Area Cde: SRMC-Sleep Versin Cde: a Page: 2

3 utpatient r cnsultative services) with acceptable results, reflective f the scpe f privileges requested fr the past 24 mnths based n results f nging prfessinal practice evaluatin and utcmes Evidence f current ability t perfrm privileges requested is required f all applicants fr renewal f privileges Cre privileges: Sleep medicine Admit, evaluate, diagnse, and prvide cnsultatin and treatment t patients f all ages presenting with cnditins r disrders f sleep, including sleep-related breathing disrders (such as bstructive sleep apnea), circadian rhythm disrders, insmnia, parasmnias, disrders f excessive sleepiness (eg, narclepsy), sleep-related mvement disrders, and ther cnditins pertaining t the sleep-wake cycle May prvide care t patients in the intensive care setting in cnfrmance with unit plicies The cre privileges in this specialty include the prcedures n the attached prcedures list and such ther prcedures that are extensins f the same techniques and skills CORE PROCEDURES LIST This list is a sampling f prcedures included in the cre It is nt intended t be an allencmpassing list, but rather is reflective f the categries/types f prcedures included in the cre T the applicant: If yu wish t exclude any prcedures, please strike thrugh thse yu d nt wish t request, then initial and date 1 Perfrmance f histry and physical exam 2 Diagnsis and management f sleep/wake disrders 3 Actigraphy interpretatin 4 Oximetry interpretatin 5 Sleep lg interpretatin SPECIAL NONCORE PRIVILEGES Practice Area Cde: SRMC-Sleep Versin Cde: a Page: 3

4 Criteria: Current subspecialty certificatin in sleep medicine r certificatin f added qualificatin in sleep medicine by the relevant American Bard f Medical Specialties r by the relevant American Ostepathic Bard OR Current certificatin by the American Bard f Sleep Medicine is acceptable fr applicants wh became certified prir t 2007 AND Prvide dcumentatin f cmpetence in perfrming that prcedure cnsistent with the criteria set frth in the medical staff plicies gverning the exercise f specific privileges Required Current Experience: Demnstrated current cmpetence and evidence f an acceptable vlume f sleep study interpretatin prcedures with acceptable results, fr 12 mnths during the last 2 years; r cmpletin f training in the past 12 mnths Renewal f Privilege: Demnstrated current cmpetence and evidence f an acceptable vlume f sleep study interpretatin prcedures with acceptable results in the past 24 mnths based n results f nging prfessinal practice evaluatin and utcmes Sleep Study Interpretatin, including via telemedicine Privilege includes interpretatin f plysmngrams (including sleep stage scring), hme sleep testing (als knwn as respiratry plygraphy r type 3 prtable mnitring), multiple sleep latency tests, and maintenance f wakefulness tests in the sleep labratry r via telemedicine Practice Area Cde: SRMC-Sleep Versin Cde: a Page: 4

5 Acknwledgment f Practitiner I have requested nly thse privileges fr which by educatin, training, current experience, and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at, and I understand that: a In exercising any clinical privileges granted, I am cnstrained by hspital and medical staff plicies and rules applicable generally and any applicable t the particular situatin b Any restrictin n the clinical privileges granted t me is waived in an emergency situatin, and in such situatin my actins are gverned by the applicable sectin f the medical staff bylaws r related dcuments Signed Date Clinical Service Chief's Recmmendatin I have reviewed the requested clinical privileges and supprting dcumentatin fr the abve-named applicant and make the fllwing recmmendatin(s): Recmmend all requested privileges Recmmend privileges with the fllwing cnditins/mdificatins: D nt recmmend the fllwing requested privileges: PrivilegeCnditin/Mdificatin/Explanatin Ntes: Print NameSignature Date Clinical Service Chief r Designee Signature Practice Area Cde: SRMC-Sleep Versin Cde: a Page: 5