Regions Hospital Delineation of Privileges Orthopedic Surgery

Transcription

1 Regions Hospital Delineation of Privileges Orthopedic Surgery Applicant s Last First M Date Instructions: Applicants must provide complete names and addresses f their references. Please DO NOT SEND letters of recommendation along with your application. These must be primary source verified by Regions Hospital. If documentation of cases procedures is required, please attach case and/ procedural logs to your delineation of privilege. CORE I - General Privileges Orthopedic Surgery Privileges Privileges include being able to admit, wk up, and provide non-surgical and surgical care to patients of all ages to crect treat various conditions, illnesses, injuries of the musculoskeletal system, including the provision of consultation. an ACGME AOA, thopedic surgery, 1. Demonstration of the perfmance of at least 100 thopedic procedures during the last 12 months, 2. Demonstration of successful participation in a hospital-affiliated fmalized residency special clinical fellowship during which at least 100 cases were perfmed assisted by applicant 3. Names and addresses of two (2) physicians whom we may contact who can attest to the competency of the applicant s request f privileges. Name of Facility: 1. Evaluation of your competency conducted by a qualified physician peer of your choice. Please include name and address of the physician whom we may contact. _ Revised 1/2007 1

2 CORE II- Moonlighting Privileges Orthopedic Surgery Procedures Privileges include being able to admit, wk up, and provide non-surgical and assist in surgical care to patients of all ages to crect treat various conditions, illnesses, injuries of the musculoskeletal system, including the provision of consultation 2. Currently enrolled in successful completion of an ACGME AOA, Orthopedic Surgery, Orthopedic Surgery Letter of recommendation from Orthopedic physician attesting to applicant s competence. Phone/Fax#: Evaluation of your competency by a physician peer. Please include name and address of the physician whom we may contact: Phone/Fax#: CORE III - Special Privileges Orthopedic Surgery Procedures Laminectomies an ACGME AOA Orthopedic Surgery, 1. Demonstration of the perfmance of at least 5 laminectomie procedures during the past 2 years, 2. Name and addresses of two (2) physicians whom we may contact to attest to the competency of the applicant s request f privileges. _ 1. Evaluation of your competency by a physician peer. Please include name and address of the physician whom we may contact. _ Revised 1/2007 2

3 Procedures Navigation Programs Spinal Metronic Brain Lab Other Trauma Metronic Brain Lab Other Total Joints Metronic Brain Lab an ACGME AOA, thopedic surgery Orthopedic Surgery and 4. Completion of training course f the specific Navigation Program to be used. 1. Names and addresses of two (2) physicians whom we may contact who can attest to the competency of the applicant s request f privileges. _ 1. Evaluation of your competency conducted by a qualified physician peer of your choice. Please include name and address of the physician whom we may contact. Other Revised 1/2007 3

4 CORE IV- Special Privileges Orthopedic Surgery Procedures Hemipelvectomy an ACGME AOA thopedic surgery, 3. Completion of Fellowship in musculoskeletal tum. 4. Board certification 1. Demonstration of the perfmance of at least 3 procedures within the past five years, 2. Contact infmation f two (2) physician peers whom we may contact to attest to your clinical competency. _ Vascular grafts of the hands and fearm an ACGME AOA thopedic surgery, 3. Completion of a Hand/ Micro-vascular fellowship 4. Board certification 1. Evaluation of your competency by a physician peer of your choice. Please include name and address of the physician whom we may contact. 1. Demonstration of the perfmance of at least 5 procedures in the previous year, 2. Names and addresses of two (2) physicians whom we may contact who can attest to the competency of the applicant s request f privileges. Name of Facility: 1. Evaluation of your competency conducted by a qualified physician peer of your choice. Please include name and address of the physician whom we may contact. _ Revised 1/2007 4

5 CORE V- Special Privileges Orthopedic Surgery Procedures Complex hand surgery an ACGME AOA thopedic surgery, 3. Completion of a Hand/ Micro-vascular fellowship 4. Board certification 1. Completion of a hand fellowship, and the certificate of added qualification (CAQ) f hand surgery, 3. Name and addresses of two physicians whom we may contact who can attest to the competency of the applicant s request f privileges. Name of Facility: Add: Ph/Fax#: 1. Evaluation of your competency by a physician peer choice. Please include name and address of the physician whom we may contact. CORE VI - Special Privileges Orthopedic Surgery Privileges Orthopedic Level I Trauma Care an ACGME AOA thopedic surgery, 1. Meets qualifications as specified in the Resources f Optimal Care of the Injured Patient (American College of Surgeons Committee on Trauma). 2. Approval of Direct of Trauma Services. 3. Documentation of 16 trauma CME credits in the past 12 months. 1. Evaluation of your competency conducted by a qualified physician peer of your choice. Please include name and address of the physician whom we may contact. 2. Approval of Direct of Trauma Services. 3. Documentation of 32 trauma CME credits in the past 24 months. Add: Ph/Fax: Revised 1/2007 5

6 TO BE COMPLETED BY APPLICANT: I agree to supply Regions Hospital Credentialing Office ( designee) with all of the infmation that has been requested of me f the privileges that I have applied f listed above. I also understand that my application f privileges will not proceed until which time that the infmation is received. Signature Date TO BE COMPLETED BY DIVISION/SECTION HEAD: I have reviewed and/ discussed the privileges requested and find them to be commensurate with his/her training and experience, and recommend that his/her application proceed. Signature Date Revised 1/2007 6

7 Regions Hospital Delineation of Privileges Conscious Sedation Privilege Administer and manage moderate sedation/analgesia (conscious sedation), a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone ` accomplished by light tactile stimulation. A patent airway is maintained and spontaneous ventilation is adequate. Cardiovascular function is always maintained. Basic education and minimal fmal training, MB BCH, DPM, DMD, DDS, an ACGME AOA, Professional Cpation training program. Required documentation and experience NEW APPLICANTS: 1. Provide documentation of successful completion of an examination provided by the Regions medical staff services Or Document experience by providing one of the following: Evidence of successful completion of a conscious sedation test with passing sce from another hospital; Governing board letter from another hospital indicating the applicant has conscious sedation privileges; Letter from Medical Staff Office at another hospital indicating specifically that the practitioner has conscious sedation privileges and the date they were granted; If a recent graduate, attestation of competency from program direct. 2. Provide documentation of current ACLS, PALS ATLS certification. REAPPOINTMENT APPLICANTS: 1. Provide documentation of perfming conscious sedation f at least ten (10) patients within the past 24 months; Or Provide documentation from Division/Section Head that attests to ongoing current competence. 2. Provide documentation of current ACLS, PALS ATLS certification. TO BE COMPLETED BY APPLICANT: I agree to supply Regions Hospital Credentialing Office ( designee) with all of the infmation being requested of me f the privileges I am applying f. I understand my application f privileges will not proceed until the infmation is received. Signature Date TO BE COMPLETED BY REGIONS HOSPITAL DIVISION/SECTION HEAD AT TIME OF REVIEW AND APPROVAL: I have reviewed and/ discussed the privileges requested and find them to be commensurate with this applicant s training and experience. I recommend this application proceed. Signature Date Revised 1/2007 7

8 Revised 1/2007 8