Medical Privileges Request Form

Circular Appendix 95–16–C.1 (04/10)
Page 13 of 13

Medical PRIVILEGES REQUEST FORM

INTRODUCTION

This Medical Privileges request form must be accompanied or preceded by a completed application for medical staff appointment, including the necessary supporting documents. Many clinical privileges pertinent to the practice of medicine and surgery are listed below. This list contains both outpatient and inpatient items. The request for privileges must reflect both the applicant’s and the facility’s/staff’s ability to carry out or support the various functions. This list is intended primarily for the generalist physician or physician extender performing these functions within the areas listed. Internists, pediatricians, and obstetricians may request additional appropriate privileges commensurate with their expertise within their specialty and the facility’s ability to support the requested privileges. They should be presented in an attached list and referenced on this form under “other.”

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item your decision to request either limited or full privileges. Limited means that the applicant may function in the area of the stated clinical privileges only under the direct supervision of a provider holding full privileges. “Direct supervision” may be fulfilled via telephone consultation, if appropriate. Full means that the applicant is entitled to function independently, following standards consistent with the medical community at large. Be sure to sign the request as indicated on page 13.

Discipline-specific supervisor or consultant: Indicate your recommendation for each requested clinical privilege by placing a check mark in the appropriate location for either full, limited, or not recommended (N.R.). Please explain any recommended limitations or denial of privileges on an attached sheet. Your recommendations are considered by the governing body when granting or not granting privileges.

I. OBSTETRICS (See Appendix C.2)	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Minor Normal prenatal/postpartum care
Normal spontaneous labor and vaginal delivery
Midline episiotomy and repair
Local and pudendal anesthesia
Repair of vaginal and cervical laceration
Management of mild preeclampsia
Amniotomy
Management of postpartum hemorrhage
Management of postpartum infection
Interpretation of external and internal fetal heart rate monitor tracings
Manual removal of placenta
Postpartum uterine exploration and/or curettage
Low forceps delivery
Curettage for incomplete abortion
Other (specify):
B. Major Multiple pregnancy
Amniocentesis
Breech delivery
Paracervical block
Induction/stimulation of labor
Cesarean section
Mid forceps delivery
Management of medical complications in pregnancy, i.e., diabetes, renal disease, severe preeclampsia
OB ultrasound
Other (specify):

Note: All clinicians granted minor or major obstetric privileges must also be qualified for and granted privileges in newborn resuscitation and stabilization.

II. Gynecology (See Appendix C.2)	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Minor I & D of vulvar or perineal abscess
Biopsy of perineum, vulva, cervix, vagina
Endometrial biopsy
Insertion/removal of intrauterine device
Dilatation and curettage
Culdocentesis
Polypectomy
Vaginal or uterine packing
Other (specify):
B. Major Pelvic exam under anesthesia
Tubal ligation
Marsupialization of Bartholin's cyst
Abdominal hysterectomy
Incidental appendectomy
Vaginal hysterectomy
A & P repair
Peritoneoscopy (laparoscopy)
Salpingoophorectomy
Other (specify):

III. Pediatrics	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Hepatic and Gastrointestinal Disease Hepatitis
Peptic ulcer disease
Diarrheas
4. Other (specify):
B. Renal Disease, Hypertension 1. Acute or chronic glomerulonephritis
2. Nephrotic syndrome
3. Hypertension
4. Chronic renal failure
5. Other (specify):
C. Pulmonary Disease 1. Uncomplicated asthma
Complicated asthma
Ventilatory management
Pneumonia
Cystic fibrosis
Other (specify):
D. Cardiac Disease 1. Nonsurgical congenital heart disease
Rheumatic heart disease
Heart failure, acute and/or chronic
Cardiac arrhythmias
Other (specify):
E. Metabolic and Endocrine Disease 1. Fluid and electrolyte problems
Diabetes mellitus
Disease of the thyroid gland
Menstrual disorders
Growth disorders
Other (specify):
F. Rheumatologic Disease 1. Lupus erythematosus
Juvenile rheumatoid arthritis
Other (specify):
G. Infectious Disease 1. Septic arthritis
Osteomyelitis
Urinary tract infection
Tuberculosis
CNS infections
Neonatal sepsis
Other (specify):
H. Hematologic and Oncologic Diseases 1. Anemias
Coagulation disorders
Thrombocytopenia
Cancer chemotherapeutic drug admin
Cancer patient management
Transfusion
Erythroblastosis
Exchange transfusion
Other (specify):
I. Newborn Nursery Care 1. Care of normal infant
Care of premature infant
Hemolytic disease of newborn
Respiratory distress syndrome
Neonatal resuscitation/emergency stabilization
Other (specify):
J. Other, Pediatrics 1. Failure to thrive
Adolescent gynecology
Well-child care
Convulsive disorders
Fever of unknown origin
Other (specify):

IV. Medicine	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Hepatic and Gastrointestinal Disease Cirrhosis
Decompensated cirrhosis
Hepatitis
Cholecystitis
Pancreatitis
Regional enteritis
Ulcerative colitis
Peptic ulcer disease
Acute G.I. bleeding
10. Other (specify):
B. Renal Disease 1. Glomerulonephritis
Pyelonephritis
Nephrosis
Acute insufficiency—conservative
Chronic insufficiency
6. Other (specify):
C. Pulmonary Disease 1. Uncomplicated pneumonia
Complicated pneumonia
Emphysema and chronic bronchitis
Pulmonary insufficiency
Pulmonary embolus
Pneumothorax
Ventilator management
Oxygen therapy
Asthma
Other (specify):
D. Cardiac Disease 1. Electrocardiographic interpretation
Congestive heart failure, acute
Congestive heart failure, chronic
Ischemic heart disease, angina
Myocardial infarction, uncomplicated
Myocardial infarction, complicated
Valvular heart disease
Pericarditis
Cardiac arrhythmias
Cardioversion-medical
Cardioversion-electrical
Thrombophlebitis
13. Other (specify):
E. Hypertension 1. Essential hypertension
2. Malignant hypertension
3. Other (specify):
F. Metabolic and Endocrine Disease 1. Diabetes mellitus
Diabetes mellitus, complicated by keto-acidosis or coma
Hypo/hyperthyroidism, uncomplicated
Hypo/hyperthyroidism, severe/complicated
Gout
Other (specify):
G. Collagen Disease 1. Lupus erythematosus
Scleroderma
Other (specify):
H. Arthritis 1. Rheumatoid arthritis
Osteoarthritis
Other (specify):
I. Hematologic and Oncologic Diseases 1. Anemias
Thrombocytopenias
Cancer chemotherapeutic drug administration
Cancer patient management
Other (specify):
J. Neurological diseases 1. Cerebrovascular accident
Convulsive disorders
Parkinsonism
Degenerative neurological disorders
Meningitis
6. Other (specify):
K. Allergy (Medical or Pediatric) 1. Desensitization
Urticaria
Other (specify):

V. Surgical or Procedural (See Appendix C.3)	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Skin I & D of abscess
Wound debridement
Incisional and excisional biopsy
Excision of benign tumors
Repair & closure of simple lacerations (not involving tendons/nerves/major vessels)
Repair & closure of complicated lacerations
Electro-surgical destruction of lesions (Fulguration)
Pilonidal cyst drainage
Lymph node biopsy
First and second degree burns
11. Other (specify):
B. Ophthalmologic 1. I & D abscess of lid
Removal of superficial foreign bodies
Corneal abrasion
4. Other (specify):
C. ENT and Plastic Surgery 1. Tracheostomy
I & D abscess/hematoma of canal/auricle
Foreign body removal from nose or ear
Laryngoscopy
Nasal packing
Nasal fracture reduction
Blepharoplasty
Myringotomy
9. Other (specify):
D. Digestive System 1. I & D perirectal abscesses
Electrocautery/excision of anal condylomata
I & D oral abscesses
Biopsy mouth, tongue or lip lesions
Repair oral lacerations
Passage & use of Sengstaken-Blakemore tube
Gastric lavage
Liver biopsy, closed
Proctosigmoidoscopy, anoscopy
Proctosigmoidoscopy, anoscopy, w/ biopsy
Diagnostic paracentesis
Therapeutic or decompressive paracentesis
Closed reduction of hernias
Gastroscopy
15. Other (specify):
E. Orthopedic 1. Muscle biopsy
Injection of tendon sheath, ligament trigger points, or bursae
Arthrocentesis
Bone marrow aspiration
Bone marrow biopsy
Closed reduction of simple fractures of phalanges, clavicles, ribs, toes
Closed reduction of simple fractures of radii, ulnae, humeri, tibiae, fibulae
Reduction of dislocations of hip, elbows, shoulders, fingers
Application of casts and splint
Non-surgical & non-neurological traction
11. Other (specify):
F. Thoracic 1. Thoracentesis
Tube thoracostomy
Pleural biopsy
Bronchoscopy
5. Other (specify):
G. Genito-urinary, Renal, Urologic 1. Hemodialysis
Peritoneal dialysis
Bladder aspiration by needle or catheter
Vasectomy
Circumcision
Meatotomy
Bladder irrigation
8. Other (specify):
H. Neurological 1. Peripheral nerve block
Lumbar puncture
Local/regional anesthesia administration
Observe for head injury
Subdural tap
6. Other (specify):
I. Vascular 1. Arterial puncture
Insertion and monitoring of CVP line
Insertion of temporary cardiac pacemaker
Cutdown for insertion of catheters
Umbilical vein catheterization
Umbilical artery catheterization
Right heart catheterization
Other (specify):
J. Emergency Procedures, Not Covered Elsewhere 1. Cricothyroidotomy
Endotracheal intubation
Insertion of oropharyngeal airway
Intracardiac injection
Pericardiocentesis
Peritoneal lavage
Use of manual and mechanical resuscitator
Use of rotating tourniquets
Use of MAST trousers
Acute drug overdoses
11. Other (specify):

VI. Psychiatric (See Appendix C.4)	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Anxiety disorders
B. Depression
C. Chronic schizophrenia
D. Substance abuse
E. Hyperactivity in children
F. Other (specify):

VII. Radiology (See Appendix C.11)	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Radiograph interpretation (with report)
B. Ultrasound interpretation (with report)
C. Injection of contrast material (venous, arterial, lymphatic)
D. Performance of x-rays 1. Chest
2. Extremities
3. Others
E. Other (specify):

Medical PRIVILEGES REQUEST FORM

1. I hereby request the clinical privileges as indicated on the forms attached.

Applicant Date

2. I hereby recommend the clinical privileges as indicated.

Supervisor/Consultant Date

3. As Chairperson of the Medical Staff Executive Committee, I hereby recommend the clinical privileges: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Clinical Director Date

4. I hereby recommend the applicant for clinical privileges.

Service Unit Director Date

5. Privileges are hereby granted: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Chairperson of the Date

Governing Body

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