|
|
- Kellie King
- 5 years ago
- Views:
Transcription
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20 ., Clinical Privileges Update Form Susan Modesitt Department of Obstetrics and I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type ofexperience): Current Privileges not to be Renewed:* ~~ ;*Privileges not renewed are not reported as being voluntarily reli~cjuished unless this is done while you are underinvestig~tion; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you,will be notified and receive a copy of the report to be filed with the National Practitioner Databank. As the Division HeadlQI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We find as follows: [1}~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. Should have clinical privileges granted but restricted as follows:, -- DA~;-- 2~~_~ -- ~lvlsl~1~n$;:il-~--~~~---~~ DATE?'~'(L DEPAROO~A~U~;:rr ~,Ii/. SIGNA~ Revised 3/112006
21 Clinical Privil{~gesUpdate Form U~RSITY C!!_ViRGINIA.Snsan Modesitt Department of bstetrics and Gy L- HEALTH SYsTEl\.1 ~ I have reviewed the privileges previously granted to me nd request the following changes to include any new therapies, procedures, or additional training ne essary to perform new privileges requested. (pleas e include supporting documentation to erify competency): New Privileges to be Added:(please indicate category le el and type of experience): Current Privileges not to be Renewed:* *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; "--pr, in return for not conducting an lnvestlgatlon or proceeding. If privileges are to be reported as voluntarily relinquished you viii be notified and receive a copy of the report to be filed with the National Practitioner Databank. CLIN IAN S ATURE As the Division Head/QI Liaisen and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ' We find as follows: G:::}'Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D Concerns noted on review with correctlve action plan in place with recommendation of reappointment ~T~'~' to the,c, IInlca"lstaff,Withprivileges as requested, but subject to a rev,e:u", ' months. [] ~o): p,wlleges granted but res c d as foilow~ :;J( J(~~(Ol ~:ATE {.,I DIVISIONft~~~SI ~~~V_~~ )v~!/~-~:..oate DEPARTMENT CHAIR SIGNATURE _ Revised 3/1/2006
22 Clinical Privileges Update Form U~TJ:VERSITY --!!'-- o/virginif:l Susan Modesitt Department 0 Obstetrics and Gy.!!!HI. JiEALTH SYS1T ~J:vl I have reviewed the privileges previously granted to me nd request the following changes to include any new therapies, procedures, or additional training n cessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category Ie el and type of experience): Current Privileges not to be Renewed:* *Privilcges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. C ICIAN SIGNATURE As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We f~ follows: ~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D D Concerns noted on review with corrective action plan in place with ~ ommendation of reappointment to the clinical staff with privileges as requested, but subject to are e n months. Should have clinical privileges granted but re DATE ATE Revised
23 Request for aser Privileges University of Vir inia Health System De artment of Ph sician Name: Please check those types of lasers that you a e requesting privileges for, and indicate type of training/experience. TYPE OF EXPERIENCE: Comp ted Formal Training Limite Experience - without formal training Extensive Experience - without formal training PRIVILEGES, Laser Privileges Requested Type of Experience Laser Surgery - Argon r. c, Laser Surgery - CO2 I Laser Surgery - Holmium Laser Surgery - KTP 4- Laser Surgery - Pulsed C A- Laser Surgery - Yag A Laser Surgery - Lite Sheer f1 S;3I/o~, A --/U/2422~~LZ: Date 7 Clinicia~ure. As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges and agree that the clinician's qualifications l-/y-ol.>..d A /1/1J Date 1approPriate., r e:. udlib l-13-0 lp Date <+;>~r-c>-b~ Department Chair Please return completed form to Clinical Staff Office, Box Rev 7(2003
24 REQUEST FOR CLINICAL PRIVILEGES Department of Obst tries and Gynecology University of Virginia ealth Sciences Center ~~~~~~~~~~~~~8 /o/~~~. ~~~~~~~~~~~~~"~~m~/?r~~ Year of Certification CJCO.L : yeaf-of. Geftification "... -'.' Admitting Privileges? ) Yes 0 No Virginia Ambulatory Surgery Center Privileges? ~ Yes o No PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. According to category, enter A, B or C in the REQUESTED column. Category A The applicant will not undertake patient management except in emergency. Category B The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties. Category C The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally. Type 1 Type 2. Type 3 According to type, enter 1, 2, or 3 (all that apply) in the EXPERIENCE column. Completed Formal Training Program Limited Experience - without formal training Extensive Experience - without formal training Ii GENERAL MEDICINE INFERTILITY Differential Diagnosis and Treatment c.. i :::~I~i.~~~::~~~:~:~~~~?:~=:::::::::::::::::::::::::::::::::::::::::::::::::::::~::::::::: :::::::::::::::~::::::::::::::::::::: Health maintenance f' I Immunization l ~ I Non-surgical evaluation and management l\ :::::::::::::::L:::~::::::::::::~:..._ ~.
25 GYNECOLOGY Antepartum care High risk e- I...f..L......_. ~;::::d:i:: risk ~ _ L. Birth control - counse ing and management c.. 1 E~ d ~~,: i ;~ E;~; i~a ti ~~ _. _ _ :::9.:~:~~~~~::~~~f.~~~~?~::::::~... C :::::~~:=~::::~::~:::~~~:::::::::::::::~:::::~ :::::::::::~:~~:::::::::::::::::: r ::::::::::::r:::::::::::::~:::::::::::...~~~!~~=..:.~~~.i.~.~.~!.~.~.._ ~.!.. Sexual counseling I u u _u. u u u u _ _ Subspecialty evaluation Endocrinology Oncology.. UroIOTc jiiiiiiiiiiiiiiw~jijiiiiiiiijiii Category Category A B According to category, enter A, B or C in the REQUESTED column. The applicant will not undertake the procedure except in emergency. The applicant will occasionally perform or assist in the performance of the procedure. Consultation will be sought in the event of anticipated or actual difficulties. Category C The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. According to type, enter 1, 2, or 3 (a// that apply).in the EXPERIENCE column. Type 1 Type 2 Type 3 Completed Formal Training Program Limited Experience - without formal training Extensive Experience - without formal training Biopsy ~~ A Cervical ~ _ 1"". ::::~=:::::::::c.::~:::::::::::::::::~::i:~:::::::::::::::::::: Endometrial Vulvar ~... C. I Conization of cervix C- I :::~::~::~::::::::::::::::::::::::::::::::::::::::::::::::::::~:::::~:::::~:::::::::::::::::::::::::::::::::~:::::::~:~::::::~:::: ::::::::T::::~::::::::::::::::::::: General surgical procedures... _ - See Surgical _ _ -- A. Hysterosalpingogram i~;;;~ti~~~ c y ~~a i~ ~ t"i ; ~ -f-'t' 7. I t i;;ig~ti~..~ ~ ~ d d;~i~~g~ - - ~ /'i '" Laparoscopy v 1 ~~r N ; ~ pi ~ ~t i~~ ~ rti ; ~ ~~d ~~ ~;;~~ i ~ I. _ _ _... u _ lc.
26 ..._ Pap.._ Smear _._..._..._.... U/S....: G. c INFERTILITY In vitro fertilization an related procedures I MATERNITY CARE/DELIVERY Amniocentesis Genetic "... u h.,'... "', ','.,... :.u :. ~.!.,",. ~::I~dard :~~:::::::~:~::~:::::==:~: :::::::::::1::::::::::::::::::::::.-...-J---- -Bio~~~I~ ~ ~~~~===~~=~: :.::..~:-:~ :;:~ ~ ~~~~~:~:;t;;hy ;~;= =,. - ~, - -..~ ': ' {-, ' Circumcision \ ::~:?!.~?~~:~:~:~~~~:::::::::::::=~:~:::::::::~:::::~:~:::~:~:=~:::::~::::::~::::::: ::~::::::::~:::~::::::::~~~:: :::~:::::::h.:::~:::::::::::::.. FHR.. ~;~ it;~i;:;g.. ~. Doppler velocimetry 1'\ 7- _ u _.nu Forceps Low-... _~~~:!: _ :~:::::::::::::~:::::::::::::::::: :=~::::~::::L:::::~:::::~::::: Intrapartum care ~i;~~i::iate risk : ~ i ~.... ~.?.~~!.~.:..~~~.~ It::.1...~~~~.?.~?..~~!~~.~~~ _... i...~~~~.~.~.::.!.~.: Lacerations repair 1st & 2nd degree../. 3rd degree & th degree A:::. 1. ij g ~ti ~~ ~t~~i;:;~ b i;;d ~ ~ ppj"y.. r:;, r.. M ~ itipie g ~~t~ t i ;~ d-;;i i ~ ~;y.. _ {i;. - 1'. :~~:~~~~~;:::~~!~~:!~~:I!:~~~~::~:~:~:~~~y.~:::::~:~:::::::::::::~~::: :::::::::::::{I;::::::::::::::::::: ::::~~::::I:::::::::::::::::::::::::: St~~ ~~ t ~~t: fe-t;i..... :. NST. fetal ~. i -... n TransabdominallTranscervical CVS 1st trimester 2nd trimester 3rd trimester u/s Basic Vacuum Targeted
27 ,, Vaginal delivery... continued Version ONCOLOGY Chemotherapy 1 SURGICAL :::~~~~~:~~~!!?:6~~~::~~~:~:~~~: ::::::~:::::::::::~:::::~::~:::::~~:::::::~:::::::: :::::::::::::::::~::::::::::::::::: :::::::::::L~:::::::::::::::::::: Radiation therapy (int cavitary implants) r: (. Unn _.. uu. u._ n n u _.. n ~ u n Sur ical rocedures - ee Sur leal Abortion D & E: < 12 weeks. t-: \... _~~.~:;..~;._~t~~~;~~~;~:.~.~.~ _=:..=&~~~~~ =.:i.~:= :...~.~.!.:~!.?~..~.~.~p..?~~:.~.~~.~ "B;~ ~i"s ~ ~ g'~~y -,." _, ;- _.!..:!?~!~... L. Biopsy - needle, excisi n I Radical G.. Simple r- \ :::~~:~~:?:~:~~~~:~y~:::::~:::::::::::::::::::~::::::::::::::~=::::::::::::::::::::::::~::: ::~:::::::::::c::::::::::~::::: ::::~:::::::::.c:::::::::::::::~:::: _.~.?.~: ~.1 "....~y.~.!?~.:~!?.y. ~.1....~..~..~ _ G. ]. _.. Debridement.... C -..E..i.~.:.~!~~~ ~y~.~.~~!!.~~!:.~..!?!.9.::.~.~:.:=~. c._. L_.. Drainage intra cavity. r / E~ d ~ ;;;~t~i~ i..~ b i~ti ; ~ - _." y.: _ 1 _ _ ' n n n~ u n Excision f' \ Fist ~i a ~e pa ir ib~~ ~i ~~d ~~i~~ ;yf - :t.. _ _ "j.._. :::~~:6:~!~:~:6:~!::~~~::~~_~~~~:~::~:~~:?:~:~~~~:::=:::::::~::::::~=:::::: ::~::::::::::::t~::::::::::::~::: :~::::::l:::::::::::::~:::::::::~:: Genital system (hysterectomy and related /' I procedures)... v r.... Hernia repair C-. \ :::8.y.:~!~:~:~~!~~y.::::::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::::::::::::::::: ::::~:::::~::k:::::::::::::::::::~::~::.:[::::::::::::::::::::::~:. Incision and drainage r- { "i~f~-; t i ~ ~ d i ~C;~d;;~s - _ t.. _ r.. "..,,... _.... _..... (_. Intraperitoneal therapy /I ~ n In vitro fertilization & related procedures... ~ ~ 1j:?- _.\ _.._. Laparoscopic surgery '--- \ :::~~~:~~~::~:::::::~:::::::::::~:::::::::::::::::~::::::~:~~:::::::::::::::::::::::::::::~:::::::. :::::::::::::::::E.::::::::::~::: :::::::::.L:::~~::::::::::::::~::: Lymphadenectomy t: l _.. u ~......n n. Lysis of adhesions... _ _ _. Needle biopsy r L N ~ d ~ bic;p~y.. - _ (:: _ _ 1 _. O ~ ph ~ ~ ~~t~;;y p~ ~ ~~e ~ t~~i~ t; ~ Para-aortic and pelvic node dissection ('"i v
28 ,... p;-~t~~p..~~ ~ ~ d..;;; ~~ ge;:;;~~t ~ - -r.l..-- _ Pre/Antenatal - See aternity Care/Delivery :::~~~: '!~~~!6:~!'~p.y~::::::: ::::::~:~~~:~:::=:::~:~~::::::~~:::::=~::::~ :~::~=::::::5.~:::::::=:::: Radical pelvic surger (including bowel & :::=:::::~=~=~::~::=::~::....~Ei.~~.:.t...!~~.:~J _ ~, ~. Retroperitoneal explo ation.. s~ ipi ~g-;;;-t ~ ~y L C \ \ r t :::~~~~~~~t:~i~::::::~::::::::: Sigmoidostomy \...-- :::~:::=:=::~~::~::::=::~:::::::::=:::::::::::. ~::::::::::::~::ff::::::::::::::::::::::::~[::::~:::::::::::::::: u _ _ _ _ Urinary tract surgery... :..,'::'. '. :::',:'...,",' ~~~~=~.~ ::::::~:::::::::I:::~~::::. Simple , - C '\- ::::::::T:::::~::~:::::::::::::::: U/S abdominal and pelvic G-.. v ~gi ~ ai..~~..~t~ ~i ~ ~..p~;:;i~-p~ ~..~~ p ~ i ; (5. _ t,... Wide..e ~cisi;:;n..io~e ~..ge~ itat t ~ ~ct..ie ~i ~ ~ ~.... \". OTHER Catheterization C- \ :~~~:~~~~~~~:::~~~:~~!:~:6::::::::::::::::::~:::::::~:::::::~:::::::::::::::::::::::::::: :~:::::::::::::::::~~::::~:::::: :~:~:]~:::~::::::::::::::::::::::.. Cy~t~~~py _, C _.... y _.. _ _.. E ~ d ;;-t ~ ~~h~ ~ i..i~ t~ b ~ti ; ~ )S(. Placement central IV access lines :::~!~:~~!~~~~:?:~y.:::::::::::::~::::::::~:::::::::::::::::::~::::=:::::::~::::~:::::::: ::::::~::::::~:::::::::..:::::::::::::::::~::::~::::~::::::::::::::: Swan Ganz catheter placement..f\.., b :::Q!.:~::::::::~:::::::~:::::::~::::::::::::::::::::::::::::::::::::::::~:::::::::::::::::::::::::::::::::: ::::::::::::::::~:::::::c.::::: ::::~::.I=:::::::~:::::::::::::: j T'~a???~4 cu ClAN / As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that clinician's qualifications are appropriate. The following indicators have been reviewed for reappointment.
29 Since the date of the last appointment, we hav following sources of quality data: reviewed applicable information from the o Physician's Health & Mental Status o Inpatient Attending Performance Morbidity and Mortality Reports o Blood Usage Reports o Drug Usage Reports o Infection Reports o Invasive/Non-Invasive Procedures o Medical Hecords Documentation We 'find as follows: o atient/family Satisfaction o entinel Events/Risk Management Reports o onsultation Attending Performance Outpatient Clinical Practice o rher: reer Review of Clinical.. Performance o I o Acceptable review with recommendation of ~ointment to the clinical staff with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in _ months. DATE DATE DEPA TMENT CHAIR clin_pri.obg R:04/11/97
Clinical Privileges Update Form Kenneth Liu Department of. Radiology I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,
More information~ ~..._..._...~..._ CLINICIAN SIGNATURE
Clinical Privileges Update Form UNlVEHSrry qrvirginiau Barbara Wilson Department of Dermatology L--. HEALTH SYsTEM ~ ~ I have reviewed the privileges previously granted to me and request the following
More informationClinical Privileges Update Form
Clinical Privileges Update Form Mark Mendelsohn epartment of Pediatrics I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,
More informationQualifications For initial appointment and core privileges in the Department of Family Medicine, the applicant must meet the following qualifications:
DEPARTMENT OF FAMILY MEDICINE Qualifications For initial appointment and core privileges in the, the applicant must meet the following qualifications: Successful completion of an ACGME or AOA-recognized
More informationTORRANCE MEMORIAL MEDICAL CENTER DEPARTMENT OF OBSTETRICS AND GYNECOLOGY. RULES AND REGULATION Effective September 30, 2014
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY RULES AND REGULATION Effective September 30, 2014 TABLE OF CONTENTS Page ARTICLE I Rules and Regulations 1 ARTICLE II Policies and Procedures 2 ARTICLE III ARTICLE
More informationUNMH Family Medicine Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective April 28, 2017: Initial Privileges (initial appointment) Renewal of Privileges (reappointment)
More informationUNMH Family Medicine Clinical Privileges
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 07/31/2015 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.
More informationObstetrics and Gynecology Clinical Privileges
Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,
More informationClinical Privileges Profile Family Medicine. Kettering Medical Center System
Clinical Privileges Profile Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested. Applicants have the burden
More information.0 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as. Clinical Privileges Update Form
Clinical Privileges Update Form ~, John Mason Department of Otolaryngology. U~-rr"tRSITY C!/ \lirgil\.;y\. HEALTH SYsTEM I have reviewed the privileges previously granted to me and request the following
More informationRegions Hospital Delineation of Privileges Family Medicine
Regions Hospital Delineation of Privileges Family Medicine Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and
More informationSCOPE OF PRACTICE PGY-1 PGY-4
GENERAL: It is the goal of the Department that its residents will have a progressive increase in authority for decision making and operative independence. As residents increase their knowledge base, clinical
More informationPrivileges for: General Surgery
Document Review: MEC 8/27/09, 2/27/2014, 1.23.2015, 4.28.2016; Board: 9/14/09, 6/29/10, 5/5/2014, 3.2.2015, 5.2.2016 ST. ELIZABETH - EDGEWOOD ST. ELIZABETH - FLORENCE ST. ELIZABETH - FT. THOMAS ST. ELIZABETH
More informationFAMILY MEDICINE CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 4/3/2013. Applicant: Check off the Requested box for
More informationSurgical Care, Centered on You
General Surgery Surgical Care, Centered on You Having surgery is an important decision, and so is choosing where to have surgery. At Woman s, your surgery will be performed by experienced specialists and
More informationRegions Hospital Delineation of Privileges Nurse Practitioner
Regions Hospital Delineation of Privileges Nurse Practitioner Applicant s Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and basic
More informationSUTTER MEDICAL CENTER, SACRAMENTO Department of Family Medicine Delineation of Privileges
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 Request Privilege Appointment [ ] Admit [ ]
More informationBenign Gynecology Level: PGY-4
Benign Gynecology Level: PGY-4 Service: University Gynecology Length of Rotation: 4 months Supervision: Chief Resident Faculty Independent activity with supervision by the attending physician assigned
More informationCredentialing Application Packet. Dear Resident Applicant,
Credentialing Application Packet Salina Family Healthcare Center A Federally Qualified Community Health Center 651 E. Prescott, Salina, KS 67401 Medical Center ~ (785) 825-7251 Dental Center ~ (785) 826-9017
More informationSupervision Residents will be supervised by attendings and upper-level residents who are competent to perform the specific procedure.
Family Medicine Residency Procedure Curriculum Elly Riley, DO Rotation Goal After completing the longitudinal and block procedural curriculum, the resident will be competent to independently perform core
More informationX X AHP Clinical Privileges Update Form Joseph Fallon, PA Department of Radiology -------I have reviewed the privileges previously granted (COP)' attached) to me and request the following
More informationGynecology Rotation for PGY 3-5
McGill University Obstetrics and Gynecology Residency Program Goals and Objectives Gynecology Rotation for PGY 3-5 Overview This document describes the Obstetrics and Gynecology residency rotation in Gynecology
More informationCRITERIA FOR GRANTING MEDICAL PRIVILEGES
CRITERIA FOR GRANTING MEDICAL PRIVILEGES Please review these categories carefully to determine those privileges for which you are qualified. Indicate your request below by checking the appropriate category.
More informationPOLICY - RESIDENT SUPERVISION DEPARTMENT OF UROLOGY (2008) - Approved UTHSCSA GME 2009
POLICY - RESIDENT SUPERVISION DEPARTMENT OF UROLOGY (2008) - Approved UTHSCSA GME 2009 Section I. Introduction The Urology Department has adopted the general supervision policy as provided by the UTHSCSA-GMEC.
More informationClinical Privileges Profile General Surgery. Kettering Medical Center System
Printed Name Clinical Privileges Profile General Surgery Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested.
More informationMidwife / Physician Agreement
Midwife / Physician Agreement This agreement between (the midwife) and (Affiliated Physician) executed this date sets forth the agreement between the parties, patterns of care between the parties and patterns
More informationDELINEATION OF PRIVILEGES - FAMILY MEDICINE
KALEIDA HEALTH Name DELINEATION OF PRIVILEGES - FAMILY MEDICINE LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency
More informationRESIDENT SUPERVISION DEPARTMENT OF UROLOGY (Revised )
RESIDENT SUPERVISION DEPARTMENT OF UROLOGY (Revised 12-31-2011) Section I. Introduction The Urology Department has adopted the general supervision policy as provided by the UTHSCSA-GMEC. A link to the
More informationSHADY GROVE ADVENTIST HOSPITAL DEPARTMENT OF OBSTETRICS AND GYNECOLOGY RULES AND REGULATIONS
RULES AND REGULATIONS I. PURPOSE The Department of Obstetrics and Gynecology is organized for the purpose of securing the highest standards of medical care for patients hospitalized in the Shady Grove
More informationAPP PRIVILEGES IN MEDICINE
APP PRIVILEGES IN MEDICINE Education/Training Licensure (Initial and Reappointment) Required Qualifications Successful completion of a PA, NP or CNS program Current Licensure as a PA, RN or CNS in the
More informationCLINICAL PRIVILEGES- WOMEN S HEALTH NURSE PRACTITIONER
Name: Page 1 Initial Appointment Department Reappointment Specialty All new applicants must meet the following requirements as approved by the governing body effective: March 4, 2015. Applicant: Check
More informationUNM SRMC GENERAL SURGERY CLINICAL PRIVILEGES.
o o o Initial privileges (initial appointment) Renewal of privileges (reappointment) Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved
More informationRESIDENT GOALS AND OBJECTIVES BY ROTATION U-2 U-2 (PGY-3,4) GOALS AND OBJECTIVES BY ROTATION.
RESIDENT GOALS AND OBJECTIVES BY ROTATION U-2 U-2 (PGY-3,4) GOALS AND OBJECTIVES BY ROTATION. The following G&O s are representative of the unique experience gained at the individual institutions and represent
More informationSCOPE OF PRACTICE PGY-5 PGY-7
GENERAL: It is the goal of the Department that its Maternal Fetal Medicine Fellows will have a progressive increase in authority ultrasound interpretation, independence in providing consultative services,
More informationKaiser Permanente Group Plan 301 Benefit and Payment Chart
301 Kaiser Permanente Group Plan 301 Benefit and Payment Chart 10119 CITY AND COUNTY OF SAN FRANCISCO About this chart This benefit and payment chart: Is a summary of covered services and other benefits.
More informationPrivileges for San Francisco General Hospital # 10
PEDIATRICS 2014 FOR ALL PRIVILEGES: All complication rates, including transfusions, deaths, unusual occurrence reports, patient complaints, and sentinel events, as well as Department quality indicators,
More information2017 Training Evaluation Form (TEF) Question List
2017 Training Evaluation Form (TEF) Question List Demographics Educational Support and Supervision Gynaecology Training Obstetrics Training APM/ATSM Subspecialty Education and Professional Development
More informationSURGICAL ONCOLOGY MCVH
SURGICAL ONCOLOGY MCVH PGY-4 and PGY-5 Medical Knowledge: Demonstrates knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences;
More informationState of New Jersey Board of Medical Examiners Midwifery Regulations Published May 19, 2003
State of New Jersey Board of Medical Examiners Midwifery Regulations Published May 19, 2003 TITLE 13. LAW AND PUBLIC SAFETY CHAPTER 35. BOARD OF MEDICAL EXAMINERS SUBCHAPTER 2A. LIMITED LICENSES: MIDWIFERY
More informationUBC Hospital. Rotation Goals and Objectives
THE UNIVERSITY OF BRITISH COLUMBIA Department of Urologic Sciences Faculty of Medicine Gordon & Leslie Diamond Health Care Centre Level 6, 2775 Laurel Street Vancouver, BC, Canada V5Z 1M9 Tel: (604) 875-4301
More informationKaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION
Kaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION 2019 Summary of Important Changes for Contract Renewals for the Kaiser Permanente Group Plan (These changes are subject to regulatory
More informationLoma Linda University Medical Center Loma Linda, CA 92354
Name: Page 1 of 7 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5) All
More informationBenefit Explanation And Limitations
Benefit Explanation And Limitations SFHP providers supply many medical benefits and services, some of which are itemized on the following pages. For specific information not covered in this table, please
More informationMember s Responsibility: Deductible, Copays, Coinsurance and Maximums
Benefits-at-a-Glance for GradCare 2018 This is intended as an easy-to-read summary. It is not a contract. Refer to the Your Benefits chapter in the Certificate for an official description of benefits.
More informationFamily Medicine Residency Surgery Rotation
Family Medicine Residency Surgery Rotation Rotation Goal The overall goal for the educational experience provided in the areas of general surgery, trauma surgery, office orthopedic surgery and sports medicine,
More informationPhysician Application
CONTROLLED RISK INSURANCE COMPANY OF VERMONT, INC. (A RISK RETENTION GROUP) CONTROLLED RISK INSURANCE COMPANY, LTD. Physician Application Please type or print responses in ink, and answer all questions
More informationEMERGENCY CARE SYSTEMS
OVERVIEW Emergency and Trauma Care Systems The DCP emergency components of essential packages WHO Emergency Care System Framework Emergency Care System Assessment Tool PREVENTION PREHOSPITAL & TRANSPORT
More informationPatient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult
Title: Documentation of Clinical Activities by UNMH Medical Staff and House Staff Applies To: UNM Hospitals Responsible Department: Office of Clinical Affairs Updated: 05/2016 Policy Patient Age Group:
More informationLoma Linda University Medical Center GENERAL SURGERY Privilege Request Form
Name: Page 1 of 9 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5) All
More informationDermatology. Anesthesiology and Perioperative Medicine. Emergency Medicine. Respiratory Care. Anesthesiology Research. Dermatology Externship
Anesthesiology and Perioperative Medicine Anesthesiology Research ANES 5002 Course Description: This course is designed to introduce the student to scientific discovery, experimental design, methodology,
More informationMD or DO or equivalent International medical training
UPMC 1 Delineation of Privileges Request Criteria Summary Sheet Facility: Specialty: Childrens Hospital of Pittsburgh of UPMC, North PEDIATRICS KNOWLEDGE MD or DO or equivalent International medical training
More informationAPP PRIVILEGES IN SURGERY
APP PRIVILEGES IN SURGERY Education/Training Licensure (Initial and Reappointment) Required Qualifications Successful completion of a PA or NP program Current licensure as a PA or RN in the state of California
More informationWelcome to Kaiser Permanente: NAME (Please Print):
Welcome to Kaiser Permanente: NAME (Please Print): You have made a great choice for your health! We value each and every member and aim to make your transition from your prior insurance company to Kaiser
More informationDELINEATION OF PRIVILEGES - PEDIATRICS AND PEDIATRIC SUBSPECIALTIES
KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES - PEDIATRICS AND PEDIATRIC SUBSPECIALTIES The responsibility of Pediatrics begins with the newborn and continues through 21 years of age. There are special
More informationGlobal Health Curriculum: Learning Objectives
OVERARCHING GOALS FOR RESIDENCY EDUCATION IN GLOBAL HEALTH These overarching goals describe the knowledge, skills and attitudes we consider necessary for consultant-level practice applied in various clinical
More informationSPECIALTY OF PULMONARY MEDICINE Delineation of Clinical Privileges
SPECIALTY OF PULMONARY MEDICINE Delineation of Clinical Privileges Criteria for granting privileges: Current board certification in Internal Medicine by the American Board of Internal Medicine or the American
More informationPrimary Care Women s Health Faculty Development Year
Version 8 Last Update Date 8/9/17 Primary Care Women s Health Faculty Development Year PROGRAM MANUAL AND EDUCATIONAL CURRICULUM Educational Director: Ann Klega, MD 1 INTRODUCTION National Need While many
More informationSANTA MONICA-UCLA MEDICAL CENTER & ORTHOPAEDIC HOSPITAL DEPARTMENT OF OBSTETRICS AND GYNECOLOGY RULES AND REGULATIONS
SANTA MONICA-UCLA MEDICAL CENTER & ORTHOPAEDIC HOSPITAL DEPARTMENT OF OBSTETRICS AND GYNECOLOGY RULES AND REGULATIONS - 2017 Page 2 of 10 I. NAME The name of the organization shall be the Department of
More informationBenefit Explanation And Limitations
Benefit Explanation And Limitations SFHP providers supply many medical benefits and services, some of which are itemized on the following pages. For specific information not covered in this table, please
More informationGeneral Surgery Clinical Privileges
Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,
More informationGlobal Surgery Package for Professional Claims
Manual: Policy Title: Reimbursement Policy Global Surgery Package for Professional Claims Section: Administrative Subsection: None Policy Number: RPM011 Date of Origin: 1/1/2000 Last Updated: 3/6/2017
More informationFamily Medicine/General Practice Clinical Privileges
Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,
More informationPEDIATRIC ENDOCRINOLOGY CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 04/03/2013. Applicant: Check off the Requested box for
More informationDERMATOLOGY CLINICAL SERVICE RULES AND REGULATIONS
DERMATOLOGY CLINICAL SERVICE RULES AND REGULATIONS 2017 DERMATOLOGY CLINICAL SERVICE RULES AND REGULATIONS TABLE OF CONTENTS I. DERMATOLOGY CLINICAL SERVICE ORGANIZATION... 3 A. SCOPE OF SERVICE... 3 B.
More informationLOMA LINDA UNIVERSITY MEDICAL CENTER SURGERY SERVICE RULES AND REGULATIONS
I. ORGANIZATION LOMA LINDA UNIVERSITY MEDICAL CENTER SURGERY SERVICE RULES AND REGULATIONS A. Membership: 1. The Surgery Service shall be made up of Physicians and Dentists who perform surgical procedures
More informationSCOPE OF PRACTICE. Internal Medicine Residency USF Health Morsani College of Medicine University of South Florida
SCOPE OF PRACTICE Internal Medicine Residency USF Health Morsani College of Medicine University of South Florida Background Internal Medicine Residency is clinical training in a supervised environment
More informationUNM SRMC SURGICAL ONCOLOGY CLINICAL PRIVILEGES.
o o o Initial privileges (initial appointment) Renewal of privileges (reappointment) Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved
More informationTRAUMA AND EMERGENCY SURGERY CORE OBJECTIVES: PGY 4
TRAUMA AND EMERGENCY SURGERY CORE OBJECTIVES: PGY 4 GOALS Through rotation on the trauma and emergency surgery service, residents shall attain the following goals: I. Patient Care A. Trauma Resuscitations
More informationUNMH Pediatric Nephrology Clinical Privileges
ll new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 07/31/2015 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.
More informationYour Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $0 single/ 3x family Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue toward the outof-pocket maximum. With respect to family plans, an individual
More informationPenrose-St Francis Hospital
Advanced Practice Nurse Please check applicable credential [ ] Nurse Practitioner [ ] Clinical Nurse Specialist [ ] Certified Nurse Midwife [ ] Certified Registered Nurse Anesthesist Area of focus _ ***************************************************************
More informationTelemedicine services $0 copay Not applicable Primary care provider (PCP) CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance
Calendar Year Deductible (CYD) 2 Plan includes an embedded individual deductible provision. An embedded deductible combines individual and family deductibles in $4,000 Single / $8,000 Family $12,000 Single
More informationq' Clinical Privileges Update Form U~lVERSTY '!VRGNA Bhiken Naik Department of Anesthesiology HEALTH SYsTEM have reviewed the privileges previously granted to me and request the following changes to include
More informationPOLICY TRANSMITTAL NO April 7, 2011 OKLAHOMA HEALTH CARE AUTHORITY
POLICY TRANSMITTAL NO. 11-14 April 7, 2011 HEALTH POLICY OKLAHOMA HEALTH CARE AUTHORITY TO: SUBJECT: STAFF LISTED MANUAL MATERIAL CHAPTER 30. MEDICAL PROVIDERS-FEE FOR SERVICE OAC 317:30-3-59, 30-3-60,
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare As a Molina Healthcare member, you will continue to receive all medically-necessary Medicaid-covered services at no cost to you. The following list of covered services
More informationObstetrics & Gynecology Department
Huntington Hospital Obstetrics & Gynecology Department Rules and Regulations October 2015 Huntington Memorial Hospital Rules and Regulations Table of Contents 1.0 SCOPE OF CARE... 1 2.0 STAFF ORGANIZATION
More informationCARDIOVASCULAR SURGERY PHYSICIAN ASSISTANT CLINICAL PRIVILEGES
Notice to Applicant: Applicants have the burden of producing information deemed adequate by University of Mississippi Medical Center (UMMC) for a proper evaluation of current competence, current clinical
More informationThe Milestones provide a framework for the assessment
The Obstetrics and Gynecology Milestone Project The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency
More informationSummary of Benefits Prominence HealthFirst Small Group Health Plan
POS Triple Choice 3000 Summary of Benefits Calendar Year Deductible (CYD) $3,000 Single / $9,000 Family $7,000 Single / $21,000 Family $21,000 Single / $63,000 Family Coinsurance 40% coinsurance 50% coinsurance
More informationSPECIALTY OF FAMILY MEDICINE Delineation of Clinical Privileges
SPECIALTY OF FAMILY MEDICINE Delineation of Clinical Privileges Criteria for granting privileges: Current board certification in Family Medicine by the American Board of Family Medicine or the American
More informationPolicy on Supervision: Roles, Responsibility and Patient Care Activities for Residents. Department of Medicine Internal Medicine Residency
Policy on Supervision: Roles, Responsibility and Patient Care Activities for Residents Department of Medicine Internal Medicine Residency Philosophy Residents are physicians in training. They develop and
More informationPolicy on Resident Supervision. University of South Florida College of Medicine General Surgery Residency Rev. July 2013
Policy on Resident Supervision University of South Florida College of Medicine General Surgery Residency Rev. July 2013 Policy Definitions: 1. Resident: A medical school graduate who is enrolled in the
More informationK-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals AEA Minimum Participation Full Participation 1, 2
Outcome Measure for Any One of the Following: Outcome Measures Meeting Either A or B: Adverse Drug Events (ADE) All measures are surveillance data Hospital Collected Anticoagulant (ADE-12) Opioid (ADE-111)
More informationJersey Shore University Medical Center Ob/Gyn Residency Program Educational Goals and Objectives for GYNECOLOGY PGY
These are the Educational Goals and Objectives for the Gynecology Rotation. Please review and become familiar with these goals and objectives. The Chief Resident on the Gynecology Rotation is responsible
More informationDelineation of Privileges and Credentialing for Critical Care Procedures
Delineation of Privileges and Credentialing for Critical Care Procedures Marialice Gulledge, DNP, ANP-BC Chief, Nurse Practitioner Trauma and Acute Care Surgery Disclosure Faculty/presenters/authors/content
More informationPRIVILEGE APPLICATION FORM - [Mercy Medical Center]
Current Privilege Status Key Practitioner's Current Privilege status is signified in ( ) preceding each privilege. G = W = Withdrawn T = Temporary P = With Proctor A = Assist with C = With Consult E =
More informationAneurin Bevan University Health Board Handover during the Intrapartum period Guideline
Handover during the Intrapartum period Guideline N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed versions of the document. The Intranet should
More informationSeasons Women s Care Patient Registration Form
Seasons Women s Care Patient Registration Form Name: of Birth: Address: City: St: Zip Home Phone: Cell: Best Number: Email: Race or Ethnicity: Marital Status: SS# Drivers Lic#: Employer: Work# Occupation:
More informationIC Chapter 2. Licensure of Hospitals
IC 16-21-2 Chapter 2. Licensure of Hospitals IC 16-21-2-1 Application of chapter Sec. 1. (a) Except as provided in subsection (b), this chapter applies to all hospitals, ambulatory outpatient surgical
More informationACHA ACHD PROGRAM CRITERIA Comprehensive Care Center
ACHA ACHD PROGRAM CRITERIA Comprehensive Care Center A. ACHD Cardiologist B. ACHD Medical Program Director C. Advanced Practice Nurse/Physician Assistant D. Registered Nurse E. Cardiothoracic Surgery and
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 02/01/12 REPLACED: 02/01/94 CHAPTER 5: PROFESSIONAL SERVICES SECTION 5.1: COVERED SERVICES PAGE(S) 11
Anesthesia Services Surgical anesthesia services may be provided by anesthesiologists or certified registered nurse anesthetists (CRNAs). Maternity-related anesthesia services may be provided by anesthesiologists,
More informationMinnesota Alliance for Patient Safety (MAPS) Informed Consent: A Model Facility Policy
Model policy: Informed consent for surgical and invasive procedures 1 Definitions: Capacity: A clinical term that refers to the ability to make rational and reasonably well informed decisions by a particular
More informationUNM SRMC Nephrology Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNM SRMC Board of Directors, effective August 213, 2017 Initial Privileges (initial appointment) Renewal of Privileges (reappointment)
More informationGeneral Internal Medicine Clinical Privileges REAPPOINTMENT Effective from July 1, 2015 to June 30, 2016
Name: Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants must meet the following requirements as approved by the governing body, effective: 04/Jun/2013. Applicant:
More informationThe McNair Centre Gynaecology outpatient department
The McNair Centre Gynaecology outpatient department This leaflet explains more about the services provided by the gynaecology outpatient department. It gives you a brief description of the main clinics
More informationINSTRUCTIONS All new applicants must meet the following requirements as approved by the UNM SRMC Board of Directors effective: June 2017:
o Initial privileges (initial appointment) o Renewal of privileges (reappointment) o Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved
More informationGUIDE TO BAYFRONT.
GUIDE TO BAYFRONT www.bayfront.org MISSION Quality healthcare for all we serve VALUES Trust, respect and dignity reflecting our responsibility to achieve healthcare excellence for our community VISION
More informationBeaumont Health System
CONTENT Prerequisites Completion in ACGME-accredited residency programs, or in Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited
More informationSunset Community Health Center, Inc.
Sunset Community Health Center, Inc. Administration 2060 W. 24th Street Yuma, Arizona 85364 Date of Application: APPLICATION FOR EMPLOYMENT AND CREDENTIALING Personal Data Full Name SS# Last First Mi Have
More informationWOUND CARE CLINICAL PRIVILEGES St. Dominic Jackson Memorial Hospital
PRINTED NAME: DATE: All new applicants must meet the following requirements as approved by the governing body, effective:. INSTRUCTIONS Applicant: Check the requested box for each privilege requested.
More information