SCHNECK MEDICAL CENTER



DECATUR COUNTY MEMORIAL HOSPITAL

CLINICAL PRIVILEGES IN EMERGENCY MEDICINE

NAME:_________________________________________DATE:__________________

QUALIFICATIONS: To be eligible for core privileges in emergency medicine, the practitioner must meet the following qualifications:

BASIC EDUCATION: M.D. or D.O.

MINIMAL FORMAL TRAINING: Completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited post-graduate training program in Emergency Medicine, Family Medicine, General Internal Medicine or General Surgery -or- Current certification or active participation in the examination process leading to certification in emergency medicine by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine.

EXPERIENCE: Applicants for initial appointment must provide documentation of active practice or training during the previous three years.

REAPPOINTMENT REQUIREMENTS: Basic Life Support competence, current demonstrated competence and an adequate volume of current experience (as specified in the ADMINISTRATION Medical Staff Credentialing Process) with acceptable results in the privileges requested for the past 24 months based on results of quality assessment/improvement activities and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges. A.C.L.S. and P.A.L.S. competence is required for all Emergency department physicians.

EXPECTATIONS: Emergency physicians must possess knowledge and skills to handle the evaluation, treatment, and stabilization for a wide range of medical/surgical conditions. Emergency medicine encompasses the immediate decision-making and action necessary to prevent death or any further disability for patients in health crises. These acute processes, however, require a limited number of emergency interventions. One of the principal responsibilities of emergency medicine staff is to distinguish between life-threatening and less acute conditions and to design the appropriate interventions to meet patient needs.

Note: If any privileges are covered by an exclusive contractual arrangement, physicians who are not party to the contract are not eligible to request the privilege(s) regardless of education, training and experience.

| Requested |CORE PRIVILEGES |

| Requested |Evaluate, diagnose and provide initial treatment and/or stabilization to patients of all ages who present in the ED |

| |with any symptoms and to determine if additional care is necessary. Arrange appropriate consultation, transfer and/or |

| |referral of all patients needing admission to a hospital or needing further outpatient care. Privileges include: |

| |cardioversion, defibrillation, intubation, conscious sedation, cricothyrotomy, treatment of patients presenting with |

| |alcohol related illnesses (intoxication, withdrawal, detoxification etc.), and treatment of toxic injestions. |

| |Privileges include emergency procedures but not ongoing inpatient care or scheduled outpatient procedures except for |

| |procedures performed during routine emergency medicine follow up visits. Procedures performed include: airway |

| |management; respiratory, cardiac and trauma resuscitation; initial management of lacerations, fractures and |

| |dislocations; evaluation and initial management of neurologic symptoms, genital/urinary symptoms, fevers, chest pain, |

| |GI bleeding, abdominal pain, and pelvic pain and/or bleeding; and any procedure that is necessary to treat a life or |

| |limb threatening condition. A practitioner, within the scope of his/her field of expertise, is allowed to make a |

| |diagnosis based on preliminary interpretation of diagnostic testing and guide treatment. |

| |Other |

| |_______________________________________ |

| |_______________________________________ |

| |_______________________________________ |

| Requested |Moderate (Conscious) Sedation: Must maintain Basic Life Support Competency and complete the DCMH Sedation & Analgesia |

| |open book test reviewing the DCMH guidelines and education material with at least 100% score for initial credentialing.|

| |If the physician has performed eight (8) or more cases at DCMH without complications within the two (2) year |

| |credentialing period, renewal credentialing will occur automatically at the time of reappointment. |

ACKNOWLEDGEMENT OF PRACTITIONER

I have requested only those privileges for which, by education, training, current experience, and demonstrated performance, I am qualified to perform, and that I wish to exercise at Decatur County Memorial Hospital.

Signed:_________________________________________Date:____________________

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← Found qualified for privileges requested.

← Modifications recommended as follows:_________________________________

_________________________________________________________________

_________________________________________________________________

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Department Chair Date

Core Privilege Form Approved:

Department Committee Date: 11-14-14

Medical Staff Date: 02-20-15

Board of Trustees Date: 02-26-15

Board of Trustees Approved Revision Date: 11-17-16

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