INITIAL CLINICAL PRIVILEGES DELINEATION FORM Department of Medicine Monmouth Medical Center

Transcription

1 INITIAL CLINICAL PRIVILEGES DELINEATION FORM Monmouth Medical Center Physician Name: Application Date: DIRECTIONS TO APPLICANTS: 1) GENERAL AND SPECIFIC PRIVILEGES: General Privileges: If you are requesting privileges to admit and care for medicine patients at Monmouth Medical Center, you must apply for privileges in the Section of General Internal Medicine. Specific Privileges: If you are requesting privileges to perform procedures, interpret tests, or conduct evaluations in consultation outside of the Section of General Internal Medicine, you must apply for these privileges within one or more of the sections of the Department of Internal Medicine, and these privileges must be approved by the appropriate Section Chief and Chair of Department. 2) SERVICE OBLIGATION GENERAL INTERNISTS: Each member of the Department of Internal Medicine in Category A must provide service to the without compensation. These include education rounds with medical students or residents, office precepting of medical students or residents, administrative service (e.g., hospital committees), or chart review (for performance improvement). 3) SERVICE OBLIGATION SUBSPECIALISTS: Each member of a subspecialty section of the Department of Internal Medicine in Category A must participate in resident teaching, clinic work, and/or ward consultation service as assigned by the Section Chief or Chair of Medicine. Date Signature of Physician Date Signature of Section Chief (if applicable) Date Signature of Chair, Department of Internal Medicine Page 1 of 19

2 GENERAL INTERNAL MEDICINE 1. Board certified in Internal Medicine, or board certification within 5 years of initial appointment 2. Section Chief of General Internal Medicine and Chair of Medicine are satisfied as to competency and currency 3. Current ACLS Certificate 4. If within 2 years of completion of residency training, must supply documentation from the residency program director indicating competency to perform procedure. If beyond 2 years of completion of residency training, must supply documentation of 2 procedures within the prior 2 years Inpatient care of medical patients* 1, 2, 3 1 and 2 by Section Chief of Chair of Criteria Applicant General Medicine Medicine Consultation in General Internal Medicine to non-internal medicine physicians and dentists 1, 2, 3, 4 1 and 2 Ambulatory care of medical patients 4 1 and 2 Lumbar puncture 1, 2, 3, 4 1, 2, and 4 Paracentesis 1, 2, 3, 4 1, 2, and 4 Arthrocentesis of knee joint 1, 2, 3, 4 1, 2, and 4 Therapeutic injection of joints 1, 2, 3, 4 1, 2, and 4 Placement of indwelling arterial lines 3 1, 2, and 4 Skin biopsy (punch) 1, 2, 3, 4 1, 2, and 4 Thoracentesis without pleural biopsy 1, 2, 3, 4 1, 2, and 4 Total parenteral nutrition 1, 3 1, 2, and completion of 1.5 hrs CME Placement of nasogastric tube 1, 2, 3 1 and 2 Placement of central venous catheters 1, 2, 3 1, 2, and 4 Advanced Cardiopulmonary Life Support 1, 2, 3, 4 1 and 3 Treadmill exercise stress test 4 1, 2, and 25 supervised cases *For patients admitted to the ICU, critical care consultation is mandatory Comments (if necessary) Page 2 of 19

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4 CRITERIA FOR PRIVILEGES AND SIGNATORY APPR`OVAL ALLERGY AND IMMUNOLOGY 1. Board certified in Allergy and Immunology, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges 2. Section Chief of Allergy and Immunology and Chair of Medicine are satisfied as to competency and currency 4 = Outpatient Dept Consultation in Allergy/Immunology 1, 2, 3, 4 1 and 2 Desensitization 1, 2, 3, 4 1 and 2 Allergen skin testing 1, 2, 3, 4 1 and 2 Supported by Requested Section Head of Supported by by Allergy & Chair of Criteria Applicant Immunology Medicine Rhinolaryngoscopy 1, 2, 3, 4 1 and 2 Comments (if necessary) Page 4 of 20

5 CARDIOLOGY 1. Board certification in Cardiology, or satisfactory completion of an approved fellowship training program during the 3 years preceding initial application for privileges. 2. Section Chief of Cardiology and Chair of Medicine are satisfied as to competency and currency 3. Current ACLS. 4. Meets criteria for COCATS* Level 2 training in adult cardiac catheterization 5. Meets criteria for COCATS* Level 3 training in adult cardiac catheterization 6. Certified by the American Board of Interventional Cardiology 7. Has performed 50 diagnostic catheterizations in the preceding year with a documented complication rate within national guidelines OR has performed 100 diagnostic catheterizations supervised by a cardiologist with current diagnostic catheterization privileges at Monmouth Medical Center 8. Has performed 100 interventional catheterizations in the preceding year OR has performed 200 interventional catheterizations supervised by a cardiologist with current interventional catheterization privileges at Monmouth Medical Center 9. Certified by the Board of Nuclear Cardiology and meets current ICANL** standards for correlation between nuclear image interpretation and angiogram results. 10. Demonstrates having met current requirements for didactic hours and supervised cases of the Board of Nuclear Cardiology. 11. Credentialed at Monmouth Medical Center in conscious sedation 12. Meets criteria for COCATS* Level 2 training in adult echocardiography. 13. Meets criteria for COCATS* Level 2 training in echocardiography with pharmacologic intervention. 14. Has read 150 contrast coronary computed tomography (CCT) examinations, interactive 50 non-contrast studies, completion of 20 hours of CCT lectures, and verification of CCT experience. 5 = Catheterization Lab 6 = Nuclear Medicine 7 = Non-invasive Cardiology 8 = Operating Room*** By Section Chief Chair of Criteria Applicant of Cardiology Medicine Consultation in cardiology 1, 2, 3, 4 1 and 2 Insertion of transvenous temporary pacemaker 1, 2, 3, 5 1, 2, and 3 Insertion of permanent pacemaker 3, 5, 8 1, 2, 3, 11 and 30 cases supervised by credentialed provider and 15 cases within last year * Core Cardiology Training Symposium of American College of Cardiology & American Society of Nuclear Cardiology ** Intersocietal Commission for Accreditation of Nuclear Medicine Laboratories ***Privileges in this location must also be approved by Chair of Surgery (continued) Page 5 of 20

6 CARDIOLOGY (continued) Programming and follow-up surveillance of pacemakers Cardioversion elective defibrillation (electrical) See previous page for all criteria 2 = Emergency Dept 5 = Catheterization Lab 6 = Nuclear Medicine 7 = Non-invasive Cardiology Requested Supported by Supported 8 = Operating Room*** By Section Chief Chair of Criteria Applicant of Cardiology Medicine 1, 3, 5, 8 1, 2, and 3 1, 3, 5, 7 1, 2, 3, and 11 Stress echocardiography transthoracic with/without pharmacologic intervention. 4, 7 1, 2, 12 and 30 supervised cases by credentialed provider Echocardiography (transesophageal) 3, 4, 7 1, 2, and 13 Echocardiography (transthoracic) 3, 4, 7 1, 2, and 12 Treadmill stress testing with/without nuclear injection Pharmacologic stress testing with/without nuclear injection 4, 6, 7 2, 3 and 50 cases supervised by a credentialed provider 4, 6, 7 2, 3 and 50 cases under supervision of a credentialed provider Insertion of pulmonary artery catheter 3, 5 1, 2, and 3 Pericardiocentesis 2, 3, 5 1, 2, 3, and 11 Administration of thrombolytic therapy to cardiac patients 1, 2, 3, 5, 7 1, 2, and 3 Perform diagnostic cardiac catheterization 5 1, 2, 3, 4, 7, and 11 Perform elective interventional cardiac catheterization 5 1, 2, 3, 5,6, and 8 for new privileges after 1/1/05 (unless within two years of completing cardiology fellowship) ***Privileges in this location must also be approved by Chair of Surgery (continued) Page 6 of 20

7 CARDIOLOGY (continued) Perform interventional cardiac catheterization in patients with acute coronary syndromes See previous page for all criteria 5 = Catheterization Lab 6 = Nuclear Medicine 7 = Non-invasive Cardiology 8 = Operating Room*** 5 1, 2, 3, 5, 6, and 11 Requested Supported by Supported by Section Chief Chair of Criteria Applicant of Cardiology Medicine Interpret nuclear cardiac studies 6 1, 2, and 9 May use 10 as substitute for 9 for 24 months only Coronary computed tomography (CCT) 7 1, 2, and 14 Perform placement of arterial stents in the following arteries after arteriography: 5 1, 2, 3, 11 and 100 peripheral cases under supervision acceptable to the chief of cardiology 2 at MMC Tilt table testing with/without pharmacologic intervention 6, 7 1, 2, 3 ***Privileges in this location must also be approved by Chair of Surgery Comments (if necessary) Page 7 of 20

8 DERMATOLOGY 1. Board certification in Dermatology, or satisfactory completion of an approved residency training program within 3 years preceding initial application for privileges 2. Section Chief of Dermatology and Chair of Medicine are satisfied as to competency and currency Consultation in Dermatology 1, 2, 3, 4 1 and 2 Punch biopsy 1, 2, 3, 4 2 Shave biopsy 1, 2, 3, 4 2 Excisional biopsy 1, 2, 3, 4 2 Cryosurgery 4 1 and 2 Electrosurgery 4 1 and 2 Laser surgery 4 1 and 2 Ultraviolet therapy 4 2 Sclerotherapy 4 2 By Section Chief of Chair of Criteria Applicant Dermatology Medicine Comments (if necessary) Page 8 of 20

9 ENDOCRINOLOGY 1. Board certification in Endocrinology, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges 2. Section Chief of Endocrinology and Chair of Medicine are satisfied as to competency and Currency Consultation in Endocrinology by Section Chief of Chair of Criteria Applicant Endocrinology Medicine 1, 2, 3, 4 1 and 2 Performance of stimulation tests Fine needle aspiration of the thyroid 1, 2, 3, 4 1 and 2 1, 2, 3, 4 1 and 2 Comments (if necessary) Page 9 of 20

10 GASTROENTEROLOGY 1. Board certification in Gastroenterology, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges 2. Section Chief of Gastroenterology and Chair of Medicine are satisfied as to competency and currency 3. Performance of minimum of 1 procedure* under the supervision of a member of the Division of Gastroenterology with the privilege (will include review of first 10 procedures at endoscopy peer review committee) *May include any combination of upper endoscopic procedures and colonoscopies. 5 = Radiology 6 = Endoscopy Suite 7 = Operating Room Consultation in Gastroenterology 1, 2, 3, 4 1 and 2 by Section Chief of Chair of Criteria Applicant Gastroenterology Medicine Flexible sigmoidoscopy with biopsy 1, 2, 3, 6, 7 1 and 2 ` Colonoscopy 1, 2, 3, 6, 7 1, 2 and 3 Colonoscopy with biopsy-polypectomy 1, 2, 3, 6, 7 1, 2 and 3 Colonoscopy with hemostasis 1, 2, 3, 6, 7 1, 2 and 3 Anoscopy with hemorrhoid 1, 2, 3, 4, 6 1 and 2 banding/coagulation Upper endoscopy 1, 2, 3, 6, 7 1, 2 and 3 Upper endoscopy with biopsy 1, 2, 3, 6, 7 1, 2 and 3 (including foreign body removal) Upper endoscopy with biopsy 1, 2, 3, 5, 6, 7 1, 2, and 3 (including stent placement) Upper endoscopy with hemostasis 1, 2, 3, 6, 7 1, 2 and 3 Upper endoscopy with variceal 1, 2, 3, 6, 7 1, 2 and 3 hemostasis Esophageal manometry 4, 6 1 and 2 Dilatation of esophagus mechanical 2, 3, 5, 6, 7 1 and 2 Pneumatic dilatation of esophagus 2, 3, 5, 6, 7 1 and 2 Insertion of Sengstaken-Blakemore 1, 2, 3, 6 1 and 2 Tube Barrett s Mucosal Ablation 5, 6, 7 1, 2, and 3 Use of small bowel tube (M-A or Cantor, etc.) 1, 2, 3, 6 1 and 2 Page 10 of 20

11 GASTROENTEROLOGY (continued) See previous page for all criteria 5 = Radiology 6 = Endoscopy Suite 7 = Operating Room Endoscopic retrograde 5, 6, 7 1, 2 and 3 cholangiopancreatic endoscopy with papillotomy stent removal stone removal Endoscopic ultrasound with or without 6, 7 1, 2 and 3 biopsy (submucosal lesions) Endoscopic ultrasound with or without 6, 7 1, 2 and 3 biopsy (pancreatico-biliary lesions) Percutaneous liver biopsy (with 3, 6 1, 2 and 3 radiologic guidance) Capsule endoscopy 6, 7 1 and 2 Bravo capsule placement and 6, 7 1 and 2 interpretation PEG/PEJ insertion and management 3, 6, 7 1 and 2 Percutaneous PEJ 3, 6, 7 1 and 2 by Section Chief of Chair of Criteria Applicant Gastroenterology Medicine Comments (if necessary) Page 11 of 20

12 GERIATRICS 1. Board certification in Geriatrics, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges 2. Section Chief of Geriatrics and Chair of Medicine are satisfied as to competency and currency Consultation in Geriatrics 1, 2, 3, 4 1 and 2 by Section Chief of Chair of Criteria Applicant Geriatrics Medicine Comments (if necessary) Page 12 of 20

13 HEMATOLOGY AND/OR ONCOLOGY 1. Board certification in hematology and/or oncology, or satisfactory completion an approved fellowship training program within 3 years preceding initial application for privileges 2. The Section Chief of Hematology/Oncology and Chair of Medicine are satisfied as to competency and currency Consultation in 1, 2, 3, 4 1 and 2 Hematology/Oncology Bone marrow aspiration and/or 1, 2, 3, 4 1 and 2 biopsy Apheresis 1, 2, 3, 4 1 and 2 Use of cancer chemotherapeutic agents, biological products, and growth factors by Section Chief of Chair of Criteria Applicant Hematology/Oncology Medicine 1, 2, 3, 4 1 and 2 Comments (if necessary) Page 13 of 20

14 INFECTIOUS DISEASES 1. Board certification in Infectious Diseases, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges 2. Section Chief of Infectious Diseases and Chair of Medicine are satisfied as to competency and currency By Section Chief Chair of Criteria Applicant Infectious Diseases Medicine Consultation in Infectious Diseases 1, 2, 3, 4 1 and 2 Comments (if necessary) Page 14 of 20

15 NEPHROLOGY 1. Board certification in Nephrology, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges 2. Section Chief of Nephrology and Chair of Medicine are satisfied as to competency and currency 3. Performance of 5 procedures satisfactorily in the presence of a physician credentialed to perform them at Monmouth Medical Center 2 = Emergency Dept 5 = Dialysis Unit 6 = Other by Section Head of Chair of Criteria Applicant Nephrology Medicine Consultation in Nephrology 1, 2, 3, 4 1 and 2 Establishment of temporary vascular access with femoral or central vein catheter Connection and disconnection of peritoneal dialysis 1, 2, 3, 5 1, 2 and 3 1, 2, 3, 4, 5 1 and 2 Initiation of hemodialysis 1, 2, 3, 5 1 and 2 Management of hemodialysis Initiation and management of hemofiltration 1, 2, 3, 5 1 and 2 1, 2, 3, 5 1 and 2 Initiation and management of 1, 2, 3, 5 1 and 2 continuous arteriovenous hemoperfusion or dialysis Percutaneous renal biopsy 3, 6 1, 2, and 3 Peritoneal catheterization for temporary peritoneal dialysis Management of chronic peritoneal dialysis Management of ambulatory peritoneal dialysis 2, 3, 5 1 and 2 1, 2, 3, 4, 5 1 and 2 1, 2, 3, 4, 5 1 and 2 Comments (if necessary) Page 15 of 20

16 NEUROLOGY 1. Board certification in Neurology, or satisfactory completion of an approved residency training program within 3 years preceding initial application for privileges 2. Section Chief of Neurology (or designee and Chair of Medicine are satisfied as to competency and currency 3. Certification by the American Board of Electroencephalography 4. Certification by the American Board of Clinical Neurophysiology 5. Certification by the American Board of Electrodiagnostic Medicine 6. Submission and approval of 5 records and interpretations to the Section Chief of Neurology or designee. 7. Board certification in Sleep Medicine, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges. 8. Approval by Director of Sleep Center 5 = EEG Unit 6 = EMG Unit 7 = Sleep Center Consultation in Neurology 1, 2, 3, 4 1 and 2 by Section Chief of Chair of Criteria Applicant Neurology Medicine Lumbar puncture 1, 2, 3, 4 1 and 2 Administration of thrombolytic therapy to neurology patients 1, 2, 3 1 and 2 Perform and interpret EEG 1, 2, 3, 5 1 and 2, and either 3 or 4, and 6 Perform and interpret EMG 1, 2, 3, 6 1 and 2, and either 4 or 5, and 6 Performance and interpretation of polysomnographic studies 1, 2, 3, 7 1, 2, 7, and 8 Comments (if necessary) _ Page 16 of 20

17 PALLIATIVE CARE 1. Board certification in Internal Medicine or Neurology, or satisfactory completion of an approved residency training program within the 3 years preceding initial application for privileges 2. Section Chief of Palliative Care and Chair of Medicine are satisfied as to competency and currency 4 = Outpatient Dept Consultation in Palliative Care 1, 2, 3, 4 1 and 2 by Section Chief of Chair of Criteria Applicant Palliative Care Medicine Comments (if necessary) Page 17 of 20

18 Department of Internal Medicine PHYSICAL MEDICINE AND REHABILITATION Consultation in Physical Medicine and Rehabilitation 1. Board certification in Physical Medicine and Rehabilitation, or satisfactory completion of an approved residency training program within 3 years preceding initial application for privileges 2. Section Chief of Physical Medicine and Rehabilitation and Chair of Medicine are satisfied as to competency and currency 3. Certification by the American Board of Clinical Neurophysiology 4. Certification by the American Board of Electrodiagnostic Medicine 5. Submission and approval of 5 records and interpretations to the Section Chief of Neurology or designee. 1 = Inpatient units 5 = EMG lab 1, 2, 3, 4 1 and 2 by Section Chief Chair of Criteria Applicant of PM&R Medicine Perform and interpret EMG 1, 2, 3, 5 1 and 2, and either 3 or 4, and 5 Pain management privileges must be approved through the Section on Pain Medicine in the Department of Anesthesiology Comments (if necessary) Page 18 of 20

19 PULMONARY MEDICINE AND/OR CRITICAL CARE 1. Board certification in Pulmonary Medicine, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges 2. Board certification in Critical Care Medicine, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges in Pulmonary Medicine 3. The Section Chief of Pulmonary/Critical Care Medicine and Chair of Medicine are satisfied as to competency and currency 4. Completion of a minimum of 1 supervised procedure 5. Board certification in Sleep Medicine, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges. 5 = Bronchoscopy Unit 6 = Other 7 = Operating Room*** 8 = PFT Suite 9 = Sleep Lab Consultation in Pulmonary Medicine 1, 2, 3, 4 1 and 3 Admission in Critical Care 2, 3 2 and 3 Consultation in Critical Care 1, 2, 3 2 and 3 Fiberoptic bronchoscopy with biopsy 2, 3, 5, 7 1, 3, and 4 by Section Head Chair of Criteria Applicant of Pulmonology Medicine Pleural biopsy 1, 2, 3, 6 1, 3, and 4 Transthoracic needle aspiration 6 1, 3, and 4 Performance of cryotherapy 2, 3, 5, 7 1, 3, and 4 Performance of endobronchial stenting 2, 3, 5, 7 1, 3, and 4 Management of ventilators 2, 3 1 or 2, and 3 Performance and interpretation of pulmonary function tests Performance and interpretation of polysomnographic studies 1, 2, 3, 4, 8 1 and 3 9 1, 3, and 5 Insertion of pulmonary artery catheter 3 2, 3, and 4 Insertion of indwelling arterial catheter 3 2 and 3 Insertion of chest tubes 1, 2, 3 1 or 2, and 3 and 4 ***Privileges in this location must also be approved by Chair of Surgery Comments (if necessary) Page 19 of 20

20 RHEUMATOLOGY 1. Board certified in Rheumatology, or satisfactory completion of an approved fellowship training program within 3 years preceding initial application for privileges 2. Section Chief of Rheumatology and Chair of Medicine satisfied as to competency and currency 3. Completion of 1 procedure satisfactorily under supervision of a rheumatologist with the privilege at Monmouth Medical Center 5 = Radiology Consultation in Rheumatology 1, 2, 3, 4 1 and 2 Arthrocentesis other than knee 1, 2, 3, 4, 5 1 and 2 Synovial biopsy 1, 2, 3, 4, 5 1, 2 and 3 by Section Chief of Chair of Criteria Applicant Rheumatology Medicine Comments (if necessary) Page 20 of 20