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 [ ] History & Physical Applicants for Core FM privileges must satisfy the following criteria: 1) Board certification in Family Medicine; or, 2) documentation of successful completion of an accredited residency program in Family Medicine, and then Board Certification within three years of completion of residency program or - for physicians non-certified within three years of completion of a residency program must have documentation of ten years hospital experience in a TJC accredited hospital. At least six (6) cases must be proctored, can include newborn cases see below for newborn proctoring requirements. Board Certification within three years of completion of a residency program or 10 years of practice in a Joint Commission accredited hospital and 2 cases Request Core Family Medicine Privileges Appointment [ ] Debridement of superficial wounds Removal of foreign bodies from canals and superficial areas I & D superficial Endometrial biopsy Biopsy of skin lesions Excision of cyst, lipoma and polyp of the skin Anesthesia local block Applicants for Core FM privileges must satisfy the following criteria: 1)3) Board certification in Family Medicine; or, 2)4) documentation of successful completion of an accredited residency program in Family Medicine and/or admissible to Family Medicine Board certification; or, and then Board Certification within three years of completion of residency program or - 3)5) for physicians non-certified within three years of completion of a residency program must have documentation of ten years hospital experience in a TJC accredited hospital. See admit proctoring requirements Board Certification within three years of completion of a residency program or 10 years of practice in a Joint Commission accredited hospital training and experience. Page 1 of 6
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 Core Obstetrical Privileges Appointment [ ] Management of low risk labor Vaginal delivery, uncomplicated low risk Mid-line episiotomy and repair Repair of perineal laceration, first, second and third degree Fetal heart rate monitoring: EFM & Fetal scalp electrode IUPC placement and monitoring Amnio infusion Labor augmentation: AROM & Pitocin Induction of labor: AROM, Pitocin & Prostaglandin Undiagnosed antepartum bleeding, evaluation and initial management Management and delivery of stillbirth Anesthesia: local, pudendal block Vacuum-assisted outlet vaginal delivery Manual removal of placenta Diagnosis and management of premature labor and premature rupture of membranes > 32 weeks tocolysis steroids Management of diet-controlled gestational diabetes Anesthesia local, paracervical block Initial appointment documentation of obstetrical training in residency or have performed at least (40) deliveries in previous three years in a TJC accredited hospital;. Granting of any obstetrical privilege is contingent on designation of a FM call group with like obstetrical privileges to cover FM obstetrical cases and, designation of a back up obstetrical call group to handle any needed further obstetrical procedures that the FM physician does not hold privileges for see special FM/Obstetrics Plan policy. First six (6) cases. Document (10) training and experience. Page 2 of 6
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 Tier One Obstetrical Privileges Appointment [ ] Mediolateral episiotomy and repair Must also have been granted Core Obstetrical Privileges and have First (2) cases 1 case [ ] Repair of fourth degree perineal laceration completed an accredited Family Medicine OB fellowship program, or the equivalent thereof (which must be approved by MEC), and provide First (2) cases 1 case [ ] Repair of deep vaginal cervix lacerations adequate documentation of all procedures and number performed. First (2) cases 1 case [ ] Low forceps delivery First (2) cases 2 cases. [ ] Complicated vacuum delivery First (2) cases 2 cases [ ] Management of placental abruption and placenta previa First (1) case None [ ] Management of PIH mild or moderate First (1) case 1case [ ] Induction of labor by mechanical means, i.e. balloon dilation or laminaria First (1) case 1 case [ ] Management and delivery of VBAC (Must have C-Section privileges to perform without consult) First (2) cases 1 case [ ] C-Section First (2) cases 2 cases [ ] Postpartum tubal ligation First (1) case 1 case [ ] Retained placenta-complicated manual removal First (1) case 1 case [ ] Retained placenta-complicated postpartum curettage First (1) case 1 per [ ] Management of hematoma First (1) case None Request Tier Two Obstetrical Privileges Appointment [ ] Management of PIH - severe and HELLP syndrome CONSULT REQUIRED Must also have been granted Core Obstetrical First (1) case 1 case [ ] External version Privileges and have completed an accredited Family Medicine OB First (1) case fellowship program, or the equivalent thereof (which must be approved by 1 case [ ] Management of multiple gestation - includes antepartum care; vaginal MEC), and provide adequate documentation of all procedures and number First (2) cases 2 cases delivery; surgical delivery; version and extraction of 2 nd twin. performed. [ ] Management of insulin-dependent diabetes of pregnancy, antepartum and delivery [ ] Management of pregnancies complicated by pre-existing medical conditions, i.e. renal disease, cardiac disease, pulmonary disease, neurologic disease, hematologic disease, etc. First (2) cases 2 cases First (2) cases 2 cases [ ] Uterine packing First (1) case None training and experience. Page 3 of 6
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 Tier Two Obstetrical Privileges Appointment [ ] Cerclage placement for incompetent cervix First (2) cases 1 case [ ] Premature labor and premature rupture of membranes < 32 weeks gestation First (2) cases 2 cases Request Core Gynecology Privileges Appointment [ ] Management of Bartholin s gland cyst or abscess I&D or marsupialization Medical management of ectopic pregnancy Medical Mmanagement of gestational trophoblastic disease Medical management of PIDLEEP conization of cervix D&C Medical abortion Suction curettage of incomplete abortion< 12 weeks Culdocentesis Anesthesia local, paracervical block Document training and experience in ten (10) cases. Same as for core Family Medicine privileges See admit proctoring requirements Board Certification within three years of completion of a residency program or 10 years of practice in a Joint Commission accredited hospital Request Special Gynecology Privileges: Appointment [ ] Mini-lap tubal ligation Documentation of experience or training in 10 cases. First (1) (2) cases 1( 2) cases [ ] D&E < 14 weeks Documentation of experience or training in 10 cases. First (2) cases 2 cases [ ] D&C Documentation of experience or training in 10 cases. First (2) cases 11 case [ ] Suction curettage of incomplete abortion< 12 weeks First (2) cases 1 case per two years [ ] Management of gestational trophoblastic disease First (1) case None [ ] Evacuation of gestational trophoblastic disease First (1) case None [ ] Culdocentesis Documentation of experience or training in 2 cases. First (2) cases 1 1 case [ ] LEEP conization of cervix Documentation of experience or training in 10 cases. First (2) cases 1 case training and experience. Page 4 of 6
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 Newborn / General Pediatric Privileges Appointment [ ] Newborn Nursery Privileges allows admission and care of the newborn in the Newborn Nursery Same as for Core FM privileges First (2) cases None *1 case [ ] Circumcision Same as for Core FM privileges First (1) case *None1 case [ ] General Pediatric Care (non-newborn) Documentation of experience or training within the previous two three years in general pediatric non-newborn care from either residency training or a TJC accredited hospital. Documentation must be in the form of a letter from the Director of the training program or from the Chief of Service of the TJC accredited hospital First (4) cases *None1 case Request Other Special Family Medicine Privileges Appointment [ ] Nasal Pack, Anterior & Posterior. Documentation of experience in 4 cases in previous three years NONE 4 cases [ ] Adult Continuing Care in Critical Care Units Completion of a Family Medicine residency program or documentation of at least two months residency training or experience in the care of patients in Critical Care Units in previous three year period; documentation must be in the form of a letter from the Director of the training program or from the Chief of Service of the TJC accredited hospital. Note: Includes ability to see and care for the patient in the critical care setting. Exception: This privilege does not include ventilator management, insertion of monitoring lines or elective intubation. Requests for these privileges must be made separately through the Medicine Department. NONE 4 cases [ ] EKG Interpretation (privilege allows physician to participate in an EKG reading panel for official EKG interpretations) Documentation of training and experience from TJC accredited hospital or training program of at least 50 EKG interpretations in previous two three years. First (6) cases NONE [ ] Treadmill Interpretation Documentation of training and experience from a TJC accredited hospital or training program of at least 10 Treadmill interpretations in previous two three years. First (2) cases NONE [ ] Post Acute Care Privilege Continuing care of the patient in the Sutter Sub- Acute Unit or Sutter Oaks Midtown 6 cases only if not requesting admit privileges NONE [ ] Vasectomy Documentation of training and experience from a TJC accredited hospital or training program in 12 procedures during previous three years First (2) cases 2 cases training and experience. Page 5 of 6
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 Other Special Family Medicine Privileges Appointment [ ] Marsupialization or I&D s of Bartholin Cyst Documentation of training and experience from a TJC accredited hospital First (1) case 1 case [ ] Venous Cutdown Documentation of training and experience from a TJC accredited hospital First (1) case 1 case [ ] Puncture, jugular, external or training program in 6 procedures during previous three years First (2) cases 2 cases. [ ] Lumbar Puncture Documentation of training and experience from a TJC accredited hospital [ ] Paracentesis Documentation of training and experience from a TJC accredited hospital [ ] Thoracentesis Documentation of training and experience from a TJC accredited hospital First (1) case 1 case First (1) case; 1 case First (1) case 2 cases Please Note: Other special privileges, i.e. Assist in Surgery, Invasive Line Monitoring, Intubation, etc. should be requested through the Medical Staff Department that grants the individual privilege. Please contact the Medical Staff Services Department (733-3097) if you have questions or need to request privilege lists for other departments. 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 Family Medicine QI/Administrative Committee Date: TEMPORARY PRIVILEGE APPROVAL Or Dept Chief (in lieu of mtg) Credentials Committee Date: Department Chief: Medical Executive Committee Date: Board of Trustees Date: Date: DOCUMENT APPROVALS: Dates: Family Medicine Administrative Committee March 21, 2006November 30, 2010 Credentials Committee April 11, 2006January 25, 2011 (outside committee) Medical Executive Committee April 25, 2006January 25, 2011 Medical Policy Committee May 10, 2006 February 3, 2011 Board of Directors June 01, 2006 February 17, 2011 training and experience. Page 6 of 6