Applicant: Please initial the privileges you are requesting in the Requested column. Service Chief: Please initial the privileges you are approving in the Approved column. MedGI GASTROENTEROLOGY 2008 (0808 MEC) FOR ALL PRIVILEGES: All complication rates, including problem transfusions, deaths, unusual occurrence reports and sentinel events, as well as Department quality indicators, will be monitored semiannually. 55.00 CORE PRIVILEGES Admit, work-up and treat adolescent and adult patients on the Medicine Wards. Consult and manage adult patients with disorders of the stomach, intestines, esophagus, liver, gallbladder, and pancreas in the ambulatory and inpatient settings. May admit patients to the CTSI Clinical Research Center. Board of Gastroenterology or a member of the Clinical PROCTORING: Review of 5 cases REAPPOINTMENT: Review of 3 cases. 55.10 SPECIAL PRIVILEGES NOTE: Special privileges 55.18-55.19 require 55.27 Diagnostic Fluoroscopy privilege 55.11 OPERATING ROOM PRIVILEGES PROCTORING: Review of 5 cases. REAPPOINTMENT: Review of 3 cases. 55.12 UPPER GI ENDOSCOPY Diagnostic and therapeutic (including sclerotherapy, banding and coagulation) 55.13 SMALL BOWEL ENDOSCOPY Printed 8/13/2012 Page 1
55.14 FLEXIBLE SIGMOIDOSCOPY 55.15 ANORECTAL AND ESOPHAGEAL MANOMETRY AND PH PROBE 55.16 COLONOSCOPY (INCLUDING BIOPSY,POLYPECTOMY, AND CAUTERY) 55.17 LIVER BIOPSY, PERCUTANEOUS 55.18 PERCUTANEOUS ENDOSCOPIC GASTROSTOMY 55.19 PNEUMATIC BALLOON DILATION OF ESOPHAGUS Printed 8/13/2012 Page 2
55.20 ENDOSCOPOIC RETROGRADE CHOLANGIOPANCREATOGRAPHY 55.21 ENDOSCOPIC ULTRASOUND (ESOPHAGEAL,GASTRIC, PANCREATIC AND RECTAL) 55.22 ESOPHAGEAL CAUTERIZATION 55.23 ESOPHAGEAL SUTURING 55.24 CAPSULE ENDOSCOPY 55.25 WIRELESS PH PROBE Printed 8/13/2012 Page 3
55.26 INTRALUMINAL STENT PLACEMENT 55.27 DIAGNOSTIC RADIOLOGY: FLUOROSCOPY PREREQUISITES: Currently Board Admissible, Board Certified, or Re-Certified in Gastroenterology or a member of the Clinical Current X- Ray/Fluoroscopy Certificate. PROCTORING: Presentation of valid California Fluoroscopy certificate; REAPPOINTMENT: Presentation of valid California Fluoroscopy certificate 55.28 PROCEDURAL SEDATION PREREQUISITES: The physician must possess the appropriate residency or clinical experience (read Hospital Policy 19.8 SEDATION) and have completed the procedural sedation test as evidenced by a satisfactory score on the examination. Currently Board Admissible, Board Certified, or Re-Certified by the American Board of Gastroenterology or a member of the Clinical Service prior to 10/17/00, and has completed at least one of the following: ABMS certification in Anesthesia or Emergency Medicine or, Management of 10 airways via BVM or ETT per year in the preceding 2 years or, Current Basic Life Support (BLS) certification by the American Heart Association PROCTORING: Review of 5 cases REAPPOINTMENT: Completion of the procedural sedation test as evidenced by a satisfactory score on the examination, and has completed at least one of the following: ABMS certification in Anesthesia or Emergency Medicine or, Management of 10 airways via BVM or ETT per year for the preceding 2 years or, Current Basic Life Support (BLS) certification by the American Heart Association 55.29 LUMBAR PUNCTURE 55.30 THORACENTESIS 55.31 PARACENTESIS Printed 8/13/2012 Page 4
55.32 CENTRAL VENOUS LINE PLACEMENT 55.33 WAIVED TESTING Privileges in this category relate to common tests that do not involve an instrument and are typically performed by providers at the bedside or point of care. By obtaining and maintaining waived testing privileges, providers satisfy competency expectations for waived testing by The Joint Commission. PREREQUISITES: Currently Board Admissible, Board Certified, or Re-Certified by an American Board in Emergency Medicine, Family Community Medicine, Medicine, Pediatrics, Obstetrics/Gynecology, or General Surgery. PROCTORING: By the Chief of the Laboratory Medicine Service or designee until successful completion of a web-based competency assessment tool is documented for each requested waived testing privilege. REAPPOINTMENT: Renewal of privileges requires every two years documentation of successful completion of a web-based competency assessment tool for each waived testing privilege for which renewal is requested. A. Fecal Occult Blood Testing (Hemoccult ) B. Vaginal ph Testing (ph Paper) C. Urine Chemistrip Testing D. Urine Pregnancy Test (SP Brand Rapid Test) Printed 8/13/2012 Page 5
I hereby request clinical privileges as indicated above. Applicant date FOR DEPARTMENTAL USE: Proctors have been assigned for the newly granted privileges. Proctoring requirements have been satisfied. Medications requiring DEA certification may be prescribed by this provider. Medications requiring DEA certification will not be prescribed by this provider. CPR certification is required. CPR certification is not required. APPROVED BY: Division Chief date Service Chief date Printed 8/13/2012 Page 6