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Name:Click here to enter name. DEPARTMENT OF MEDICINEREQUEST FOR SPECIFIC PRIVILEGESGROUP 5Privileges in the Department of Medicine are granted for both clinical levels and specific procedures. Clinical levels are defined as:10.01?Category I - Non-Board Certified Internist. May admit to all areas. Consultation required for the Neurovigil Unit, ICU, and complicated cases in the CCU.10.02?Category II - Board Certified in Internal Medicine. May admit to all areas. Consultation may be required in the specialty units unless the individual demonstrates specific training or skills in that area.10.03?Category III - Board Certified internist who has completed subspecialty training. May admit to all areas, but may require consultation in areas other than his subspecialty. Recognized consultant in his subspecialty and may be a consultant in Internal Medicine.Specific clinical privileges in the subspecialties must be granted by the subspecialty area in which the privileges are sought; please indicate the privileges you wish to be considered for, based on your documented training, experience, and current competency:1.00Section of Cardiology1.01?Internal Pacemaker Placement1.02?Cardiac Catheterization1.03?Elective Cardioversion1.04?Placement of Swan-Ganz Catheter1.05?Elective Pericardiocentesis1.06?Maximal or Submaximal Stress Testing1.07?EKG Interpretation1.08?Interpretation M-mode Echo, Sector & Doppler Echocardiogram1.10?Cardiac Electrophysiology Studies1.11?Intra-Aortic Balloon Pump1.12?Percutaneous Transluminal Coronary Angioplasty1.13?Transesophageal Echocardiogram1.14?Temporary Pacemaker1.15?Directional Coronary Atherectomy1.16?Electrophysiology Testing1.17?ICD Implantation/Generator Exchanges/Checks1.18?Stent Replacement1.19?Transluminal Extraction Atherectomy1.20?Endomyocardial Biopsy1.21?Intracoronary Stents1.22?ICD Interrogation1.23?Radial Artery Approach to Cardiac Catheterization1.24?Loop Recorder Implantation2.00Section of Dermatology2.01?Intralesional Injection2.02?Pinch Grafts2.03?Chemosurgery2.04?Cryosurgery5.05?Skin Biopsy3.00Section of Gastroenterology3.01?Liver Biopsy3.02?Small Bowel Biopsy3.03?Endoscopic Variceal Sclerosis3.04?ERCP3.05?Sphincterotomy3.06?Percutaneous Transhepatic Cholangiography3.07?Endoscopic Sphincterotomy w/Biliary Drainage & Stone Removal3.08?Esophageal Prosthesis Placement (Endoscopic Gastrostomy Tube)3.09?Rubber-band Ligation, Hemorrhoids3.10?Manometry (Esophageal/Anorectal)3.11?Endoscopic Sphincterotomy w/Stone Removal(12)1.01?Gastroscopy(12)1.02?Peritoneoscopy(12)1.06?Sigmoid, Flexible, Diagnostic(12)1.07?Sigmoid, Rigid, Diagnostic(12)1.08?Laparoscopy(12)1.09?Colonoscopy(12)1.10?GI Endoscopy using General Anesthesia(12)1.11?Colonoscopy with Polypectomy(12)1.12?Sigmoid, Flexible with Biopsy & Polypectomy(12)1.13?Sigmoid, Rigid with Biopsy & Polypectomy(12)3.06?Esophagoscopy(12)3.09?Lithotripsy(12)3.48?Percutaneous Endoscopic Gastrostomy4.00Section of Heme Oncology4.01?Combination Chemotherapy with Consultation4.02?Combination Chemotherapy without Consultation4.03?Immunotherapy5.00Section of Internal Medicine5.01?Lumbar Puncture5.02?Bone Marrow Aspiration5.03?Paracentesis5.04?Thoracentesis5.05?Skin Biopsy5.06?Joint Aspiration and Injection5.07?Placement of CVP Lines5.08?Placement of Arterial Lines5.09?Marrow Biopsy5.10?Removal of Tenckhoff Catheter5.11?Placement Double Lumen Medi-Port(12)3.46?Sigmoid, Flexible with Biopsy(12)3.47?Sigmoid, Rigid with Biopsy6.00Section of Neurology6.01?Carotid Arteriogram6.02?Brachial Arteriogram6.03?Isotope Ventriculocisternography6.04?Cisternal Tap6.05?Pneumoencephalogram6.06?Ventricular Tap6.07?EEG Interpretation6.08?EEG Activation (Pharmacologic)6.09?EEG - Special Techniques6.10?Myelography6.11?Electromyography, (includes EMG/NCS)6.12?Nerve Conduction Studies6.13?Evoked Responses/Potentials (VER,BAER)7.00Section of Nephrology7.01?Establishment of AV Shunts and Fistulae7.02?Placement of Permanent Peritoneal Catheters7.03?Hemodialysis7.04?Peritoneal Dialysis7.05?Renal Biopsy7.06?CAVF,SCUF8.00Section of Pulmonary Disease8.01?Pulmonary Biopsy8.02?Bronchogram8.03?Pleural Biopsy8.04?Needle Aspiration/Lung8.06?Chest Tube Insertion8.07?Endotracheal Intubation8.08?Ventilator Care*8.09?Polysomnograms8.10?Pleuroscopy, Thoracoscopy(12)1.03?Bronchoscopy9.00Section of Rheumatology9.01?Synovial Biopsy11.00Section of Physical Medicine/Rehabilitation11.01?ElectromyographyOthers(12)2.00?TPN/PPN*(12)3.00?Yag Laser*(12)3.01?CO 2 Laser*(12)3.08?Administration of IV Anesthesia/Analgesia when loss of reflex may occur(12)3.17?KTP/Yag Laser*_____________________________________________________________________________________________________SignatureDate*************************************************************************************Department:Reviewed and recommended, as requested:_____Reviewed and recommended, with exception:_____Reviewed but not recommended:__________________________________________________________________________________________ChairpersonDateMedical Staff Executive Committee:Reviewed and recommended, as requested:_____Reviewed and recommended, with exception:_____Reviewed but not recommended:_____Date_______________Board of Hospital Managers:Reviewed and approved, as requested:_____Reviewed and approved, with exception:_____Reviewed but not approved:_____Date_______________* Requires written documentation of training and demonstrated competency.Note: If privileges are denied, limited, or granted other than as requested, documentation must be provided. ................
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