DEPARTMENT OF SURGERY
DELINEATION OF PRIVILEGES FOR HAND SURGERY
Name: ________________________________________________
Not
Req.
Req.
Privilege
Skin & Subcutaneous Tissues
I & D of abscess
Repair laceration superficial
Repair laceration deep
Fulguration skin lesions
Excision and Repair
Pinch/Davis
Split Thickness
Full Thickness
Pedicle graft
Rotation flap
Treatment of Burns
1st degree
2nd degree
3rd degree
Lymph Node
I & D of Abscess
Excision/Biopsy
Musculo-Skeletal
Repair of Muscle
Repair of Tendon
Repair of Nerve
Excision of ganglions
Release of nerves
Elbow (Ulnar)
Wrist (Median)
Open Method
Endoscopic
Excision/biopsy of soft tissue
Excision/biopsy of bones
Total excision of tumors
Amputations
Finger
Hand
Forearm/arm
Date: __________________
Disarticulation, shoulder
Orthopedic Hand
Removal of Foreign Bodies
Percutaneous drainage of
Abscess
Hematoma
Cyst
Extremities - Plastic repair of
Tendons/muscles
Joints
Fascia
Nerves
Bones (hand only)
I have requested only those privileges for which by education, training, current experience and demonstrated performance
I am qualified to perform. I also request the ability to do any procedure in an emergency situation.
Applicant’s Signature: ________________________________________ Date: ________________
As part of the appointment / reappointment process, I, as Chairman of the Department, have reviewed this physician’s
privileges and recommend approval or continuation of these privileges and the additions noted.
Department Chair’s Signature: ___________________________________Date: ________________
Broadway and Mary’s Avenue Campuses