SUTTER MEDICAL CENTER, SACRAMENTO

Transcription

1 Department of Surgery & Dental Section - Delineation of Privileges INITIAL: [ ] RENEWED: [ ] DATE: ADDITIONAL: [ ] Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Sutter Oaks Midtown or Capitol Pavilion Surgery Center and exercise of privileges is based on the type of care, treatment and services provided at each facility. If you plan to use radiology equipment including the fluoroscope, you must provide a current operating permit that is issued by the Radiologic Health Branch of the California Department of Health Services. To request Privileges, please place an X in the request column. In box, indicate the number of identified procedures performed in previous 24 months from any facility. If the condition/privilege you desire is not included on this form, please submit a separate written request along with appropriate documentation of training and/or experience. Request Privilege Appointment [ ] Admitting Privileges Adult None None None [ ] Admitting Privileges Pediatric None None None [ ] History and physical privileges (Class I & II Anesthesia)-A Training and Experience: Documentation of completion of an approved training program in oral and maxillo-facial surgery. Documentation will be in the form of confirmation in writing by the chief of service that the training program subscribed to prescribed minimums of 4 months of anesthesia, 2 months of medicine, 2 months of surgery, and provided adequate training and experience in the performance of histories and physicals. None None The anesthesiologist must always retain the right to request physician consultation on cases where doubt as to risk exists -A- INDICATES OUTPATIENT Page 1 of 6

2 Department of Surgery & Dental Section - Delineation of Privileges Request Oral Maxillofacial Appointment General requirements for all applicants Documentation of experience in the previous two years as a primary surgeon in at least six cases as well as the procedures being requested from either a residency or fellowship case listing (if the applicant recently completed training) or a case listing from where the applicant has been practicing. Some procedure specific criteria may also require a letter from the Director or Chief of Services. First six (6) cases must be proctored regardless of the type of procedure Six (6) cases as a primary surgeon and procedure specific requirements 1. Basic Dental Privileges (General Restorative and Basic Emergency Dentistry) - All dentists who meet qualifications for membership and the minimum standards for basic dental privileges may be considered for privileges in general restorative dentistry. (Minimum standards for basic dental privileges shall be completion of one year of an accredited dental residency program). 2. Specialists - Dentists practicing one of the dental specialties recognized by the American Dental Association and who meet the above noted membership criteria may be accorded privileges consistent with those recognized to be within the scope of practice of the specialty of the appropriate American Board or a minimum of 10 years experience as an attending dental surgeon, with privileges comparable to those being requested or privileges will be granted on an individual basis depending on the applicant's training and experience. 3. Operating Room Privileges - The formal hospital training to qualify dentists for management and care of the hospitalized patient, which includes use of the Operating Rooms shall be at least one year of training in a hospital dental internship or residency approved by the American Dental Association. [ ] Dentoalveolar surgery-a -A- INDICATES OUTPATIENT Page 2 of 6

3 Department of Surgery & Dental Section - Delineation of Privileges Request Oral Maxillofacial Appointment [ ] Apicoectomy, with or without root canal therapy-a [ ] Frenectomy (labial or lingual-a [ ] Management of maxillofacial infections-a [ ] Surgical removal of impacted teeth-a [ ] Alveolar ridge extension (Maxillary or mandibular with grafting) -A [ ] Surgery of the temporomandibular joint-a [ ] Enucleation of cysts of jaws-a [ ] Excision of benign hard and soft tissue lesions -A [ ] Dental implants -A [ ] Foreign body removal from jaws and adjacent -A [ ] Oral Antral Fistula repair -A [ ] Removal of sialolith from salivary ducts-a [ ] Caldwell-luc procedures on maxillary sinus for conditions of dental or dysfunctional including grafting- A [ ] Repair of maxillofacial lacerations - A [ ] Surgical corrections of maxillomandibular deformities with and without bone grafts -A [ ] Surgery of salivary glands submaxillary and sublingual -A- INDICATES OUTPATIENT Page 3 of 6

4 Department of Surgery & Dental Section - Delineation of Privileges Request Type of Lasers Appointment [ ] CO 2 Laser -A Surgeons requesting laser privileges must show that they have the appropriate training and/or experience in the safe use of laser equipment by meeting one of the following criteria: l. Graduation from an approved training program in Surgery where laser application was part of the active training format. Verification shall be in the form of a letter from the Director of the training program. OR None None 2. Documentation of successful completion of a section approved post-graduate course with hands-on experience, designed to familiarize practicing physicians with laser technologies, safety and application. Request Laser Procedures Appointment [ ] Gingivectomy -A [ ] Hyperplastic tissue -A [ ] Frenectomy -A [ ] Uncovering implants -A [ ] Dysplasia -A [ ] Lichen planus -A [ ] Vascular lesions -A [ ] Biopsy -A [ ] Lesion on anticoagulated patients -A -A- INDICATES OUTPATIENT Page 4 of 6

5 Department of Surgery & Dental Section - Delineation of Privileges Request Adult Appointment [ ] Surgical continuing care privileges in critical care units (no other medical issues involved or patient must be managed by a physician member of the medical staff.) Continuing care privileges in the critical care units includes the ability to see and care for the patient in the critical care setting. The privilege does not include ventilator management, elective intubation or insertion of invasive monitors. Requests for those privileges must be requested separately from continuing care privileges in critical care units. Request Pediatric Appointment [ ] Surgical and general pediatric continuing care privileges in privileges in pediatric intensive care unit (PICU) where there are no other medical or child life issues involved. *If there are medical or child life issues the patient should be managed in tandem with an appropriate member of the pediatric staff. Request Other Appointment [ ] Post-Acute Care Privilege Continuing care of the patient in Sutter Oaks Midtown. [ ] Evaluation and Consultation of Cleft Palate and Craniofacial Anomaly Clinic Patients. -A- INDICATES OUTPATIENT Page 5 of 6

6 Department of Surgery & Dental Section - Delineation of Privileges Please Note: The surgeon in charge is responsible for judging whether or not an assistant is required for any procedure listed. Acknowledgment of Practitioner: I understand that (a) in exercising clinical privileges granted, I am constrained by Medical Staff Policies and Procedures, Rules and Regulations, and (b) any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws. I hereby attest to having performed the stipulated number of procedures as indicated above, thereby meeting the criteria for those privileges I have requested. ************************************************************************************************************************ COMMITTEE APPROVALS Surgery QI/Administrative Committee Date: Or Dept Chief (in lieu of mtg) Credentials Committee Date: Medical Executive Committee Date: Board of Directors Date: TEMPORARY PRIVILEGE APPROVAL Department Chief: Date: FORM APPROVALS: Oral Surgery & Dental Surgery Section Date: 12/2/2010 Surgery Administrative Committee: Date: 2/3/2011 Credentials Committee: Date: 2/8/2011 Medical Executive Committee: Date: 2/22/2011 Medical Policy Committee: Date: 3/3/2011 Board of Directors Date: 3/14/2011 -A- INDICATES OUTPATIENT Page 6 of 6