SCHNECK MEDICAL CENTER



DECATUR COUNTY MEMORIAL HOSPITAL

CLINICAL PRIVILEGES IN OBSTETRICS & GYNECOLOGY

NAME:_________________________________________DATE:__________________

QUALIFICATIONS: To be eligible for core privileges in OB/GYN, 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 Obstetrics and Gynecology.

EXPERIENCE: Applicants for initial appointment must provide documentation of at least 100 deliveries in the past 24 months and performance of at least 50 gynecological surgical procedures in the past 24 months. Recent residency completion fulfills this requirement.

REAPPOINTMENT REQUIREMENTS: 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.

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.

| |CORE PRIVILEGES - OBSTETRICS |

| |Privileges to admit, evaluate, diagnose, consult and treat female patients presenting in any condition or stage of |

| |pregnancy, injuries or disorders of the reproductive system. Privileges include resuscitation of newborn, |

| |circumcision of the newborn, amniocentesis, amniotomy, incidental appendectomy, diagnostic ultrasound, management of |

|Requested |labor, induction of labor with medication, vaginal deliveries, forceps delivery, vacuum extraction, version/rotation |

| |of fetus, intrauterine pressure monitoring, episiotomy with repair, obstetrical laceration repair, manual removal of |

| |placenta, oxytocin management, cesarean sections and related procedures and all other procedures related to normal |

| |and complicated delivery, all high risk pregnancies including major medical diseases that are complicating factors in|

| |pregnancy. 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 |CORE PRIVILEGES - GYNECOLOGY |

| |Admission, evaluation, diagnosis, consultation and pre-, intra- and post-operative care necessary to correct or treat|

| |female patients of all ages presenting with illnesses, injuries and disorders of the gynecological or genitourinary |

| |system and treatment of non-malignant illnesses and injuries of the mammary glands to include incision and drainage |

|Requested |of abscess, hysteroscopy, abdominal and vaginal hysterectomy, anterior posterior vaginal repair, Bartholin |

| |cystectomy, biopsy, cervical amputation, cauterization and conization, colpectomy, colpocleisis, colposcopy, |

| |condyloma/warts excision, cryosurgery, culdocentesis, culdoscopy, D&C, endometrial ablation, fistulectomy, hematoma |

| |evacuation, hymenotomy, diagnostic or operative, laparoscopic assisted vaginal hysterectomy and diagnostic |

| |ultrasound, insertion/removal of uterine device, laparoscopy, exploratory laparotomy, oophorectomy, ovarian cyst |

| |resection, salpingectomy, uterine/vaginal suspension, vulvectomy, protectomy, proctoscopy, catherization, diagnostic |

| |cystoscopy and ureteral repair. 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 |

| |_______________________________________ |

| |_______________________________________ |

| |_______________________________________ |

SPECIAL NON-CORE PRIVILEGES

| 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:____________________

-----------------------

← Found qualified for privileges requested.

← Modifications recommended as follows:_________________________________

_________________________________________________________________

_________________________________________________________________

___________________________________________ __________________

Department Chair Date

Core Privilege Form Approved:

Department Committee Date: 02-11-15

Medical Executive Committee Date: 02-20-15

Board of Trustees Date: 02-26-15

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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download