APPLICATION FOR APPOINTMENT TO MEDICAL STAFF BAFFIN REGIONAL HOSPITAL IQALUIT, NU

Transcription

1 APPLICATION FOR APPOINTMENT TO MEDICAL STAFF BAFFIN REGIONAL HOSPITAL IQALUIT, NU Name: Your completed application MUST include COPIES of the following documents, otherwise it will not go forward to the credentials committee: Graduation Diploma (Professional School/University) Specialist Certificate (if applicable, CCFP, FRCS, etc.) Current License Nunavut (License to Practice in Nunavut) Current Liability Insurance Certificate Nunavut Billing Number Curriculum Vitae Evidence of Continuing Education All sections of this form must be completed prior to forwarding to the Credentials Committee for approval. Please ensure that copies of all supporting documentation, as noted above, have been included. PLEASE FAX TO (867) AND MAIL ORIGINALS TO: MEDICAL SECRETARY PHONE NO (867) BAFFIN REGIONAL HOSPITAL BOX 1000 STN 1036 IQALUIT NU X0A 0H0 RECOMMENDATION/COMMENTS OF THE CHIEF OF STAFF/CREDENTIALS COMMITTEE (Baffin Region ) Date Signature Name (please print) 1

2 I hereby apply for appointment to the medical staff of the Baffin Regional Hospital. FULLNAME: (Surname) (First) (Middle) DATE OF BIRTH: / / PLACE OF BIRTH: _ HOME ADDRESS: TELEPHONE NO: OFFICE ADDRESS: TELEPHONE NO: 1. LICENSE TO PRACTICE IN NUNAVUT Yes No DATE OF LICENSE NUMBER (Copy to be provided) 2. CANADIAN MEDICAL PROTECTIVE ASSOCIATION MEMBERSHIP # CATEGORY OTHER MALPRACTICE INSURANCE (Copies to be provided) DO YOU HAVE ANY MALPRACTICE SUITS PENDING OR SETTLED? Yes No If yes, give date and particulars. 3. Nunavut Billing Number 4. EDUCATIONAL QUALIFICATIONS: (copies to be provided) MEDICAL (Degree) (University or School) (Year) 2

3 POSTGRADUATE QUALIFICATIONS (diploma, certificates, degrees or fellowships) _ (Qualification) (Speciality) (University or College) (Year) (Qualification (Speciality) (University or College) (Year) _ (Qualification) (Speciality) (University or College) (Year) OTHER MEDICAL TRAINING (internships, traineeships, etc., listed in chronological order) _ (Date) (Appointment) (Institution) _ (Date) (Appointment) (Institution) _ (Date) (Appointment) (Institution) 5. CERTIFICATION EXAMINATIONS: (copies to be provided) Royal College of Physicians and Surgeons of Canada: Yes Eligible: Yes No No Speciality Date College of Family Physicians of Canada: Date Yes No 6. HAVE YOU EVER PARTICIPATED REGULARLY IN RECOGNIZED PROGRAMS FOR CONTINUING MEDICAL EDUCATION RE SELF- EVALUATION? Yes No (MAINPRO/MOCOMP) (Copies of recent certificates to be provided) 3

4 7. PROFESSIONAL PRACTICE - prior to this application Yes No Give date, location and type of practice: 8. HOSPITAL STAFF MEMBERSHIPS (past and present: dates, hospitals, staff category and extent of privileges) 9. TEACHING APPOINTMENTS (past and present) (Date) (Appointment) (Institution) (Date) (Appointment) (Institution) (Date) (Appointment) (Institution) 10. CONTRIBUTIONS TO MEDICAL LITERATURE Yes No Please list 11. MEMBERSHIP IN MEDICAL SOCIETIES (Please list) 4

5 12. HAVE YOU EVER BEEN DENIED HOSPITAL PRIVILEGES FOR WHICH YOU HAVE APPLIED? Yes No If yes, give date and particulars 13. HAVE YOUR HOSPITAL PRIVILEGES EVER BEEN REDUCED, SUSPENDED, REVOKED OR NOT RENEWED FOR ANY REASON? Yes No If yes, give date and particulars 14. HAVE YOU EVER VOLUNTARILY RELINQUISHED PART OR ALL OF YOUR HOSPITAL PRIVILEGES? Yes No If yes, give date and particulars 15. ARE YOU CURRENTLY UNDER INVESTIGATION BY A HOSPITAL OR THE NUNAVUT MEDICAL REGISTRAR, OR ANY OTHER LICENSING AUTHORITY? Yes No If yes, give particulars 5

6 References: One reference to be from the Chief of Staff or from the Chief of Department OR director of postgraduate training program in the last hospital in which the applicant trained or held an appointment. All references listed to include the full name, position and mailing address DECLARATION In making this application for appointment to the medical staff, I declare that I am the person named in this application and I acknowledge receipt of a copy of the medical staff bylaws and I agree: 1. to abide by the Public Hospitals Act, the bylaws of the health centre, rules and regulations thereof, and the health centre=s policies; 2. to not be a party to the division of fees under any guise whatsoever; I understand that any infraction of the above agreement may result in the suspension of any or all of my privileges at the Baffin Regional Hospital. I hereby apply for membership on the medical staff in the following category: 6

7 STAFF GROUP (SEE BYLAWS FOR FULL DESCRIPTION) ACTIVE (Full or part-time, but BAFFIN REGIONAL HOSPITAL (is your main hospital) ASSOCIATE (First six months of active staff (BAFFIN REGIONAL HOSPITAL) CONSULTING (Visiting specialists) COURTESY (BAFFIN REGIONAL HOSPITAL) is not your main hospital, parttime away contract) HONORARY (by nomination, on retiring) LOCUM TENENS (for short or long-term locums) DATE SIGNATURE 7

8 MEDICAL STAFF Privileges in: Medicine: Anaesthesia: Surgery: Obstetrics: Minor Surgery: PREAMBLE This list of privileges is intended to cover routine situations but not all conceivable emergencies. In emergency situations all members of the medical staff are expected to do their best to save life and limb regardless of the privileges which have been granted. All members of the medical staff are expected to use judgement in the exercise of these privileges and to obtain assistance from other members of the staff in conditions where they feel inadequately prepared even though the privileges as outlined may technically cover the condition. The granting of privileges for a group of procedures means that the staff member is considered competent to judge which procedures, if any, falling within this group he/she can safely and adequately carry out. Consultations are expected in any complicated or difficult problem as well as in those conditions where consultations are required by medical staff rules. Approved by Medical Requested by Advisory Committee 1. Admitting Privileges to include the admission and primary care of patients and the writing of all diagnostic and treatment orders in the emergency and all nursing units 2. Medical Privileges Family Practice/Ambulatory Care Adult Emergency/Critical Care Emergency Procedures: Central Line Insertion Intubation Conscious Sedation ACLS - Level Care ATLS Level Care 8

9 3. PEDIATRICS BAFFIN REGIONAL HOSPITAL IQALUIT, NU Major privileges including: Critical pediatrics Minor privileges including: Newborn, premature baby care and ill newborn care Other paediatrics, exclusive of critical pediatrics 4. ANAESTHESIA Privileges including: General anaesthesia Spinal anaesthesia Regional anaesthesia 5. DIAGNOSTIC Contrast procedures under fluoroscopy Ultrasound Stress testing 6. SURGICAL A. Minor Procedures Minor Repair of uncomplicated lacerations including peripheral nerve blocks Removal of lesions and drainage of abscesses of skin and subcutaneous tissues Removal of corneal foreign body Closed reduction of simple fractures Bone marrow aspiration and biopsy Aspiration and injection of joints Minor skin grafting 9

10 SURGICAL cont d Approved by Medical Requested Advisory Committee B. Endoscopy and Associated Procedures Gastroscopy Sigmoidoscopy Colonoscopy Laryngoscopy Bronchoscopy C. Intestinal and Abdominal Laparotomy, Laparoscopy Appendix and contiguous tissues Hernias of abdominal wall Ischio rectal abscesses Haemorrhoidectomy Other procedures on the rectum and perirectal tissues Cholecsytectomy and common bile duct procedures Bowel resections and anastomosis Operations on the stomach and lower esophagus Open biopsy and excisions of lesions Surgery of spleen and pancreas D. Breast E. Neck F. Oral Breast biopsy Mastectomy I & D of deep abscess Excision of cysts, lymph nodes and other deep lesions Surgery of salivary glands Thyroidectomy Fractures of the mandible and maxilla Opening of salivary ducts 10

11 G. Ear, Nose and Throat Tonsillectomy and adenoidectomy Antral lavage I & D peritonsilar and retropharyngeal abscesses Removal of nasal polypi Tracheostomy, Cricothyroidotomy H. Eye Enucleation of the eye I. Thoracic Thoracotomy for drainage J. Vascular Ligation and excision of varicose veins Embolectomy Indwelling venous access catheter K. Musculoskeletal and Skin Scar Revisions Revision Amputation Extensor tendon repair Other tendon repair Open reduction of fractures or dislocations Reductions of fractured hips, including femoral head replacement Arthroscopy and arthrotomy Other operations for the correction of minor bone or soft tissue deformity Skin grafting L. Urological Vasectomy Excision of hydroceles Circumcision (other than newborn) Other operations on external genitalia Cystoscopy Transurethral prostatic and bladder resections Open or closed removal of urinary tract calculi Nephrectomy and partial nephrectomy Cystectomy 11

12 M. Neurosurgery Repair and decompression of peripheral nerves Sympathectomy (surgical or chemical) N. GYNAECOLOGY Abdominal Hysterectomy Dilation and curettage Hysterosalpingogram I & D and excision of lesions of vulva and vagina Cone biopsy and other operations on the cervix Laparoscopy Tubal ligation Excision of ectopic pregnancy Vaginal hysterectomy and oopherectomy Aspiration and Currettage O. OBSTETRICS Low risk obstetrics Prostaglandin Induction Oxytocin Induction Vacuum Assisted Delivery Ceasarian Sections Forceps Assisted Delivery 1 st & 2 nd Degree Tear Repair 3 rd & 4 th Degree Tear Repair Manual Removal of Placenta 12

13 I,, certify that my past training and experience has been of such nature and duration that I now consider myself competent to proficiently perform the procedures marked above. Date Signature Approved by the Medical Advisory Committee Date Signature (CHIEF OF STAFF) Approved by the Director of Medical Affairs Date Signature (Director) 13