UNIVERSITY HOSPITAL



UNIVERSITY HOSPITAL

DEPARTMENT OF SURGERY

SECTION OF PODIATRY

REQUEST FOR PRIVILEGES

To be eligible to request clinical privileges, the following threshold criteria must be met.

EDUCATION: DPM

TRAINING:

Successful completion of an approved two years of Podiatric Residency with at least one year comprised of a

Podiatric Surgical Residency (PSR-12). The residency program must have been approved by the Council on

Podiatric Medical Education (CPME) during the time of training. Applicant must meet the requirements for

board certification outlined in the Medical Staff Bylaws.

EXPERIENCE:

The initial applicant must be able to demonstrate training and/or experience on a level commensurate with

specialty training from an accredited Podiatric residency program or current competency in providing

medical/surgical management and/or treatment to patients within the scope of core privileges for Podiatry.

Adequate documentation of this performance requires submission of a case list and a reference letter. All initial

applicants at completion of residency and/or fellowship must provide an official case list and letter of

recommendation assessing performance from the Residency and/or Fellowship Program Director. All initial

applicants beyond 12 months of residency/fellowship completion must provide a case list from the hospital

where the applicant has been actively practicing for the last year and a letter of recommendation assessing

performance from the hospital’s Chief of Staff or Department Chair.

The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E.

according to the Medical Staff Bylaws. Reappointment is based upon unbiased, objective review of result

of care according to the hospital’s existing quality mechanisms.

CORE PRIVILEGES:

(This list is a sampling of privileges included in the core but is not intended to be an all-encompassing list

but rather reflective of the categories/types of privileges included in the core.)

REQUESTED GRANTED

|Admission of patients | | |

|Provision of consultation, including evaluation, diagnosis and ordering of diagnostic | | |

|studies and procedures for patient with general podiatric problems. | | |

|Core I | | |

|(Requires completion of one year CPME recognized podiatric surgical residency) | | |

|Surgical and non-surgical treatment of clinical problems related to the digital and forefoot | | |

|Digital surgery (Hammertoe repair, fusions) | | |

|Osteotomy & ostectomy (digital and metatarsal) | | |

|Soft tissue repairs and excisions – digits and forefoot | | |

|Simple bunionectomy | | |

|Amputations of the digits | | |

|Excision of toe nails | | |

|Morton’s neuroma excision | | |

|Forefoot exostectomy | | |

|Capsulotomy/tenotomy digital M-P joints | | |

|Fasciotomy, plantar (simple, Steindler) | | |

|Repair Laceration | | |

|STJ arthroeresis with implant | | |

|Core II | | |

|(Requires completion of a two year CPME recognized podiatric surgical residency) | | |

|Extension of simple surgical procedures of the hindfoot | | |

|Sesamoidectomy | | |

|Fractures of digits and metatarsals - ORIF & closed reduction | | |

SECTION OF PODIATRY

REQUEST FOR PRIVILEGES

PAGE 2

REQUESTED GRANTED

|Core II Continued | | |

|(Requires completion of a two year CPME recognized podiatric surgical residency) | | |

|Hallux valgus repair with distal osteotomy | | |

|Hallux valgus repair with proximal osteotomy | | |

|Hallux valgus repair with cuneiform osteotomy | | |

|Hallux valgus arthroplasty without prosthesis, including Regnauld | | |

|Hallux valgus repair, with prosthesis | | |

|Hallux valgus repair with fusion (M-P or Lapidus) | | |

|Metatarsal osteotomy, lesser and ostectomy | | |

|Excision of soft tissue neoplasms, foot | | |

|Jones suspensions (+) Hallux IP fusion | | |

|Osteotomies of the midfoot and arthrodesis | | |

|Neurolysis of the foot | | |

|Fractures of the forefoot & midfoot | | |

|Retrieval of foreign body - foot | | |

|Osteomyelitis management - foot | | |

|Management of the foot in septic diabetic states | | |

|Bone Graft Harvest - Foot only | | |

|Retrocalcaneal exostosis | | |

|Midfoot exostectomy and rearfoot | | |

|Accessory bones of foot | | |

|Repair of Tendon Trauma | | |

|Coblation foot or ankle | | |

|Skin graft or rotational flap | | |

|Simple flatfoot repair | | |

|Core III | | |

|(Requires completion of a three year CPME recognized podiatric surgical residency) | | |

|Extension of surgical procedures to the lower extremity to and including the ankle joint | | |

|Flatfoot reconstruction with osteotomy, bone grafts, etc. | | |

|Cavus foot reconstruction with osteotomy, fusions | | |

|Arthrodesis/osteotomy midfoot | | |

|Arthrodesis, with implants | | |

|Major rearfoot arthrodesis – triple, subtalar | | |

|Fractures of the rearfoot – tarsals and ankle (ORIF & closed reduction) | | |

|Osteomyelitis management – foot and ankle | | |

|Skin grafts or rotational flaps | | |

|Talar dome repairs | | |

|Bone graft harvest, foot & ankle (implant & handle) | | |

|Extensive forefoot reconstruction: Panmetatarsal surgery, pansuspension of metatarsals, or Hibbs suspensions | | |

|or with tibialis anterior suspensions with or without multiple Metatarsal osteotomies | | |

|Osteotomies of the midfoot & rearfoot | | |

|Grice extra-articular arthrodesis | | |

|Tarsal osteotomy | | |

|Tarsal capsulotomy or capsulorrhaphy | | |

|Pantalar arthrodesis | | |

|Repair of lacerations involving all soft tissue structures of the foot | | |

|Ankle Arthroplasty | | |

|Ankle stabilization | | |

|Heel Cord Repair | | |

|Neurolysis of posterior tibial nerve | | |

SECTION OF PODIATRY

REQUEST FOR PRIVILEGES

PAGE 3

|Excluded privileges: may not independently treat the following conditions, but shall | | |

|refer the patient to a properly qualified physician. | | |

|Life-threatening lesions including, but not necessarily restricted to, proximally advancing | | |

|infections or malignant tumors. | | |

|Limb threatening lesions including, but not necessarily restricted to, proximally advancing | | |

|infection, ischemia, malignant tumor, crush injuries (excluding digits), and traumatic | | |

|injury resulting in major vascular compromise. | | |

|Neonatal club foot | | |

Applicants requesting any other special privileges listed below must present documentation of training in

each privilege requested with a letter from the training director attesting to the applicant’s competence

and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff

and the Governing Board of University Hospital.

SPECIAL PRIVILEGES to include: REQUESTED GRANTED

|Laser Surgery | | |

|Extracorporeal Shockwave Therapy | | |

|Moderate Sedation – Only applicants with Core II and III privileges | | |

|The applicant is required to submit a separate letter of | | |

|request for any privilege not included on this form. | | |

________________________________________ ___________________________

Applicant’s Signature Date 9/07

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