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DEPARTMENT OF MEDICINE
REQUEST FOR SPECIFIC PRIVILEGES
GROUP 5
Privileges in the Department of Medicine are granted for both clinical levels and specific procedures.
Clinical levels are defined as:
10.01
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10.02
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10.03
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Category I - Non-Board Certified Internist. May admit to all areas. Consultation
required for the Neurovigil Unit, ICU, and complicated cases in the CCU.
Category II - Board Certified in Internal Medicine. May admit to all areas. Consultation
may be required in the specialty units unless the individual demonstrates specific
training or skills in that area.
Category III - Board Certified internist who has completed subspecialty training. May
admit to all areas, but may require consultation in areas other than his subspecialty.
Recognized consultant in his subspecialty and may be a consultant in Internal Medicine.
Specific clinical privileges in the subspecialties must be granted by the subspecialty area in which the
privileges are sought; please indicate the privileges you wish to be considered for, based on your
documented training, experience, and current competency:
1.00
1.01
1.02
1.03
1.04
1.05
1.06
1.07
1.08
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
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Section of Cardiology
Internal Pacemaker Placement
Cardiac Catheterization
Elective Cardioversion
Placement of Swan-Ganz Catheter
Elective Pericardiocentesis
Maximal or Submaximal Stress Testing
EKG Interpretation
Interpretation M-mode Echo, Sector & Doppler Echocardiogram
Cardiac Electrophysiology Studies
Intra-Aortic Balloon Pump
Percutaneous Transluminal Coronary Angioplasty
Transesophageal Echocardiogram
Temporary Pacemaker
Directional Coronary Atherectomy
Electrophysiology Testing
ICD Implantation/Generator Exchanges/Checks
Stent Replacement
Transluminal Extraction Atherectomy
Endomyocardial Biopsy
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1.21
1.22
1.23
1.24
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Intracoronary Stents
ICD Interrogation
Radial Artery Approach to Cardiac Catheterization
Loop Recorder Implantation
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Section of Dermatology
Intralesional Injection
Pinch Grafts
Chemosurgery
Cryosurgery
Skin Biopsy
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Section of Gastroenterology
Liver Biopsy
Small Bowel Biopsy
Endoscopic Variceal Sclerosis
ERCP
Sphincterotomy
Percutaneous Transhepatic Cholangiography
Endoscopic Sphincterotomy w/Biliary Drainage & Stone Removal
Esophageal Prosthesis Placement (Endoscopic Gastrostomy Tube)
Rubber-band Ligation, Hemorrhoids
Manometry (Esophageal/Anorectal)
Endoscopic Sphincterotomy w/Stone Removal
Gastroscopy
Peritoneoscopy
Sigmoid, Flexible, Diagnostic
Sigmoid, Rigid, Diagnostic
Laparoscopy
Colonoscopy
GI Endoscopy using General Anesthesia
Colonoscopy with Polypectomy
Sigmoid, Flexible with Biopsy & Polypectomy
Sigmoid, Rigid with Biopsy & Polypectomy
Esophagoscopy
Lithotripsy
Percutaneous Endoscopic Gastrostomy
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Section of Heme Oncology
Combination Chemotherapy with Consultation
Combination Chemotherapy without Consultation
Immunotherapy
2.00
2.01
2.02
2.03
2.04
5.05
3.00
(12)
(12)
(12)
(12)
(12)
(12)
(12)
(12)
(12)
(12)
(12)
(12)
(12)
3.01
3.02
3.03
3.04
3.05
3.06
3.07
3.08
3.09
3.10
3.11
1.01
1.02
1.06
1.07
1.08
1.09
1.10
1.11
1.12
1.13
3.06
3.09
3.48
4.00
4.01
4.02
4.03
2
5.00
(12)
(12)
5.01
5.02
5.03
5.04
5.05
5.06
5.07
5.08
5.09
5.10
5.11
3.46
3.47
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Section of Internal Medicine
Lumbar Puncture
Bone Marrow Aspiration
Paracentesis
Thoracentesis
Skin Biopsy
Joint Aspiration and Injection
Placement of CVP Lines
Placement of Arterial Lines
Marrow Biopsy
Removal of Tenckhoff Catheter
Placement Double Lumen Medi-Port
Sigmoid, Flexible with Biopsy
Sigmoid, Rigid with Biopsy
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Section of Neurology
Carotid Arteriogram
Brachial Arteriogram
Isotope Ventriculocisternography
Cisternal Tap
Pneumoencephalogram
Ventricular Tap
EEG Interpretation
EEG Activation (Pharmacologic)
EEG - Special Techniques
Myelography
Electromyography, (includes EMG/NCS)
Nerve Conduction Studies
Evoked Responses/Potentials (VER,BAER)
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Section of Nephrology
Establishment of AV Shunts and Fistulae
Placement of Permanent Peritoneal Catheters
Hemodialysis
Peritoneal Dialysis
Renal Biopsy
CAVF,SCUF
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Section of Pulmonary Disease
Pulmonary Biopsy
Bronchogram
6.00
6.01
6.02
6.03
6.04
6.05
6.06
6.07
6.08
6.09
6.10
6.11
6.12
6.13
7.00
7.01
7.02
7.03
7.04
7.05
7.06
8.00
8.01
8.02
3
(12)
8.03
8.04
8.06
8.07
8.08
8.09
8.10
1.03
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Pleural Biopsy
Needle Aspiration/Lung
Chest Tube Insertion
Endotracheal Intubation
Ventilator Care*
Polysomnograms
Pleuroscopy, Thoracoscopy
Bronchoscopy
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Section of Rheumatology
Synovial Biopsy
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Section of Physical Medicine/Rehabilitation
Electromyography
9.00
9.01
11.00
11.01
(12)
(12)
(12)
(12)
2.00
3.00
3.01
3.08
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(12)
3.17
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Others
TPN/PPN*
Yag Laser*
CO 2 Laser*
Administration of IV Anesthesia/Analgesia when loss of reflex may
occur
KTP/Yag Laser*
_____________________________________________________________________________________________________
Signature
Date
*************************************************************************************
Department:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed but not recommended:_____
_____________________________________________________________________________________
Chairperson
Date
Medical Staff Executive Committee:
Reviewed and recommended, as requested:_____
4
Reviewed and recommended, with exception:_____
Reviewed but not recommended:_____
Date_______________
Board of Hospital Managers:
Reviewed and approved, as requested:_____
Reviewed and approved, with exception:_____
Reviewed but not approved:_____
Date_______________
* Requires written documentation of training and demonstrated competency.
Note: If privileges are denied, limited, or granted other than as requested, documentation must be
provided.
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