SCHNECK MEDICAL CENTER



DECATUR COUNTY MEMORIAL HOSPITAL

CLINICAL PRIVILEGES IN RADIOLOGY

NAME:_________________________________________DATE:__________________

QUALIFICATIONS: To be eligible for core privileges in radiology, 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 residency program in Radiology.

EXPERIENCE: Applicants for initial appointment must be able to demonstrate performance and interpretation of an adequate volume of radiological tests or procedures commensurate with the subspecialty and be able to provide documentation as requested.

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.

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 |

| |General Diagnostic Radiology |

|Requested |Procedures include chest, gastrointestinal (including GI contrast agents), genitourinary (including |

| |intravenous urography, cystography), mammography and salpingography. Arthrography (intra-articular |

| |contrast agents), Computerized Tomographic Scanning (head and body), Myelography, Invasive Procedures |

| |(abscess and fluid drainage, percutaneous cholangiogram, needle biopsy, drain placement), Fluoroscopy, |

| |Stereotactic Breast Biopsy, Bone Densitometry (DEXA). |

| |Magnetic Resonance Imaging (MRI) |

| |Ultrasound |

| |General (OB, pelvic, abdominal, chest, head and neck, breast, amniocentesis), Vascular |

| |Nuclear Medicine |

| |Diagnostic Imaging (thyroid, kidneys, bone scan, gallbladder), Therapeutic (thyroid therapy), Cardiac |

| |Imaging |

| |Other |

| |Breast MRI |

| |Cardiac CTA – Cardiac Calcium Scoring |

| |PET Imaging |

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:____________________

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← Found qualified for privileges requested.

← Modifications recommended as follows:_________________________________

_________________________________________________________________

_________________________________________________________________

___________________________________________ __________________

Department Chair Date

Core Privilege Form Approved:

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ÃDepartment Committee Date: 11-07-14

Medical Staff Date: 02-20-15

Board of Trustees Date: 02-26-15

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

Core Privilege Form Approved:

Credentials Committee Date: June 14, 2006

Medical Executive Committee Date: June 21, 2006

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