Clinical Privileges
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Community Health Services of Addison County Open Door Clinic Clinical Privileges Delineation for Family Practice Requested Granted _____ _____ _____ _____ _____ _____ Pediatrics Routine preventative and acute care of children including immunization Evaluation and management of children and adolescents with condition/problem with no serious threat to life with or without local complications of minimal severity Other _____ _____ Adult Medicine Routine preventative and acute care of adults _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Evaluation and management of medical conditions of low complexity, such as uncomplicated pneumonia Evaluation and management of medical conditions of moderate complexity, such as pneumonia complicated by COPD and Hyperglycemia Pre and post operative medical consultation Other________________________________ Other________________________________ _____ _____ _____ _____ _____ _____ Cardiovascular EKG Interpretation CPR Other________________________________ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Dermatology Skin Biopsy Foreign Body Removal Laceration Repair Incise, drain, excise abscess Cryotherapy Soft tissue injection Toenail removal Burn management Skin neoplasia management and treatment Other_________________________________ Requested Granted _____ _____ _____ _____ _____ _____ Gynecology Evaluation and management of gyn problems of low and moderate severity Routine preventive gynecology care Other______________________________ _____ _____ _____ _____ _____ _____ _____ _____ HEENT Foreign body removal Remove impacted cerumen Packing of epistaxis Other______________________________ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Orthopedics Joint aspirations/injection Bursa aspiration/injection Splint/cast/manage uncomplicated fractures/dislocations Ganglion cyst aspirations Other______________________________ _____ _____ _____ _____ Pulmonary Spirometry interpretation Other______________________________ _____ _____ _____ _____ Fecal occult blood testing/interpretation Other______________________________
