HealthAlliance DELINEATION OF PRIVILEGES FOR INTERNAL MEDICINE. Name: Date:
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1 DELINEATION OF FOR INTERNAL MEDICINE Please indicate to which HealthAlliance healthcare facility(s) you are interest in applying: The Broadway Campus (TKH) Mary s Avenue Campus (BH) Margaretville Hospital (MH) (Privileges marked N/A at MH are not available at Margaretville Hospital) Woodland Pond (WP) Candidate physician has completed an accredited three-year post-graduate training program and is eligible to sit for the Board Examination of the ABIM. (All department physicians must meet these criteria unless exempted by Chairman of the Department). With Specialty in the following discipline(s): Please check those that apply. Allergy/Immunology Cardiology and Cardiovascular Disease Cardiac Cath Critical Care Medicine Dermatology Endocrinology Gastroenterology and Hepatobiliary Disease Geriatrics Infectious Disease Metabolic Diseases Nephrology and Hypertension Neurosciences Oncology / Hematology Palliative Medicine Pediatrics Pulmonary Disease Substance Abuse / Methadone Treatment and Maintenance Rehabilitation Medicine Renal Disease Rheumatology Wound Care Others: Please specify Priv. ALLERGY/IMMUNOLOGY BIOPSY (PERCUTANEOUS) PROCEDURES Liver (N/A at MH) Allergy Desensitization Renal (N/A at MH) Urticaria Pleura (N/A at MH) Serum Sickness Lung (N/A at MH) Asthma w/densitization Pericardial (N/A at MH) Pericardum (N/A at MH) Bone Marrow ARTHRITIS CENTRAL LINES Double Lumen (N/A at MH) Rheumatoid Triple Lumen Osteoarthritis Gouty Page 1 of 7
2 DELINEATION OF FOR INTERNAL MEDICINE Priv ASPIRATION PROCEDURES Thoracentesis Thoracentesis - Aspiration & chemotherapy (N/A at MH) Paracentesis Joint Aspiration Pericardiocentesis (N/A at MH) Bone Marrow (N/A at MH) CARDIAC DISEASES Therapy of Cardiac Failure Congestive Heart Failure acute Congestive Heart Failure Chronic & intractable Coronary Heart Disease w/angina Coronary Heart Disease w/infarction Coronary Heart Disease w/coronary insuff. Bacterial Endocarditis Cardiac Arrhythmia Myocardial infarction Myocardial infarction w/shock Myocardial infarction with serious arrhythmia Myocardial infarction with cardiac arrest Myocardial infarction with congestive failure Myocardial infarction recurrent Myocarditis Pericarditis CARDIAC DIAGNOSTIC TESTING Cardiac Stress Test Cardiac Stress Test Nuclear (N/A at MH) Trans-Esophogeal Echocardiogram Cardiac CT Diagnosis and Interpretation (N/A at MH) Botulinum toxin injection Chemical face peels DERMATOLOGY Collagen injections Cryosurgery Destruction of benign and malignant tumors Electrosurgery Excision of benign and malignant tumors with simple, intermediate, and complex repair techniques, including flaps and grafts Intralesional injections Interpretation of specially prepared tissue sections, cellular scrapings, and smears of skin lesions by means of routine and special (electron and florescent) microscopes Potassium hydroxide examination Tzanck smears Patch tests Photomedicine, phototherapy, and topical/systemic pharmacotherapy Scalp surgery Sclerotherapy Skin and nail biopsy Soft tissue agumentation Peptic Ulcer bleeding GASTROINTESTINAL DISEASES Peptic Ulcer perforated Peptic Ulcer obstructed Page 2 of 7
3 DELINEATION OF FOR INTERNAL MEDICINE CARDIAC PROCEDURES ECG Interpretation With report Cardioversion: medical Cardioversion: electrical Swan Ganz Catheter (N/A at MH) Temporary Pacemaker Ulcerative Colitis Regional Ileitis Intestinal obstruction Pancreatitis Malabsorption Cholecystitis COLLAGEN DISEASES Lupus Erythematosus Periorteritis Nodosa Thrombatic thrombocytopenic Purpura Dermatomyositis Scleroderma Necrotising Granulomatosis HEMATOLOGICAL DISEASES Leukemia acute Leukemia chronic Hemorrhagic Diathesis Primary Anemia SPECIAL CARDIAC PROCEDURES Cardiac Catheterization (complete additional privilege form) (N/A at MH) Cardiac Monitoring Cardiac Pacemaker Transvenous (N/A at MH) CVP Lines Echocardiogram Electrocardiographic Interpretation Electroencephalographic Interpretation (N/A at MH) ENDOSCOPY W/BIOPSIES Esophagoscopy With Dilation of Esophagus With Ligation/Clipping/Sclerosis Esophogeal Varices Gastroscopy Peritoneascopy (N/A at MH) Proctoscopy Sigmoidoscopy Bronchoscopy Capsular Endoscopy (TKH Only) (N/A at MH) Stent (N/A at MH) Endotracheal Intubation Pediatric Endoscopy Colonoscopy ERCP (N/A at MH) PEG Substance Abuse / Methadone Treatment and Maintenance HEPATIC DISEASES Cirrhosis w/bleeding varices Cirrhosis w/coma Cirrhosis decompensated Hepatitis Differential diagnosis of jaundice HYPERTENSION Essential, unresponsive Malignant Complicated with cardiac insuff. Complicated with renal insuff. Toxemia of Pregnancy (N/A at MH) Page 3 of 7
4 DELINEATION OF FOR INTERNAL MEDICINE NEUROLOGICAL DISEASES Stroke acute Stroke rehabilitation Meningitis/Encephalitis Convulsive States Parkinsonism degenerative Parkinsonism demyelinating METABOLIC & ENDOCRINE DISEASE Therapy of Diabetic Coma Diabetes Mellitus w/acidosis Diabetes Mellitus w/coma Thyroid conditions Thyroid Conditions with thyrotoxic crisis Thyroid Conditions with Coma Parathyroid Conditions Pituitary Conditions Cushing s Syndrome Addison s Disease Pheochromocytoma Aldosteronism Sex Hormone Abnormalities Others: Please list NEUROLOGICAL PROCEDURES Spinal tap Myelogram (N/A at MH) EEG EMG ONCOLOGY / HEMATOLOGY Cancer Chemotherapy by protocol Bone Marrow Biopsy (N/A at MH) Aspiration Intrathecal Chemotherapy (N/A at MH) PULMONARY DISEASES Pneumonia complicated Pneumonia uncomplicated Emphysema w/pulmonary insuff. Emphysema w/coma Pulmonary Infarction Pneumothorax, spontaneous RENAL DISEASES Therapy of Renal Failure Nephritis Pyelonephritis Nephrosis Acute and chronic kidney disease RENAL PROCEDURES Dialysis, Hemodialysis (N/A at MH) Dialysis CAPD MISCELLANEOUS Thrombophlebitis Acute Peripheral Embolism Paracentesis -Diagnostic Abdominal Tap -Therapeutic Decompression Pericardiocentesis (N/A at MH) Peritoneal Dialysis Peritoneoscopy (N/A at MH) Phlebography (N/A at MH) Page 4 of 7
5 DELINEATION OF FOR INTERNAL MEDICINE SPECIAL PROCEDURES Arterial Puncture and Arterial Line Placement Arteriography (N/A at MH) Bronchograms (N/A at MH) Bronchial Brushing (N/A at MH) Bronchial Lavage CONSCIOUS SEDATION (ACLS ) MISCELLANEOUS CONTINUED Phonocariography Interpret. (N/A at MH) -With Crosby Capsule & Shiner Tube (N/A at MH) Venous Cut-Down, simple Venous pressure and circulation time Pulmonary Function Testing and Interpretation Radio-Isotope Therapy (N/A at MH) Percutaneous Tracheostomy Esophogeal Tamponade w/senstaken Tub Gastric Lavage and Cytology Hyperal imentation Insertion of Temporary Pacemaker (N/A at MH) Lymphangiography (N/A at MH) Tube Thoracostomy Critical Care Ultrasound Hemodialysis Shunt Placement PALLIATIVE MEDICINE Admit, evaluate, diagnose, and provide primary care or consultative services to all patients with life-threatening illness who require, or may require, specialist-level palliative care services. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed below and such other procedures that are extension of the same techniques and skills. Administration and management of palliative sedation Assessment of pertinent diagnostic studies Director treatment and formation of a treatment plan Management of common comorbidities and complications and neuropsychiatric comorbidities Management of psychological, social, and spiritual issues of palliative care patients and their families Req. Performance of pain-relieving procedures Provision of appropriate advanced symptom control techniques, such as parenteral infusional techniques Symptom management, including patient and family education, psychosocial and spiritual support, and appropriate referrals for other modalities, such as invasive procedures. Other: Page 5 of 7
6 DELINEATION OF FOR INTERNAL MEDICINE Skin & Subcutaneous Tissues I&D of Abscess Repair Laceration Superficial Repair Laceration Deep Fulguration Skin Lesions Excision and Repair Bio-engineered skin grafts (N/A at MH) WOUND CARE Treatment of Burns 1 st degree 2 nd degree 3 rd degree (N/A at MH) Wound debridement Excisional biopsy of skin Removal of superficial and subcutaneous cysts. If there are other privileges you would like to request that are not contain in this privilege list, please print them clearly in the table below: I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform. I also request the ability to do any procedure in an emergency. Applicant s Signature: Date: Page 6 of 7
7 DELINEATION OF FOR INTERNAL MEDICINE I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and: Recommend all requested privileges Recommend privileges with the following conditions/modifications: Do not recommend the following requested privileges: Privilege Condition / modification / explanation Department Chair s Signature: Date: Mary s Avenue and Broadway Campuses Department Chair s Signature: Date: Margaretville Hospital Page 7 of 7
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