Obstetrics & Gynecology Clinical Privileges
Name:
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Effective from
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☐Initial privileges (initial appointment)
To
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☐Renewal of privileges (reappointment)
All new applicants must meet the following requirements as approved by the governing body,
effective
Applicant: Check the "Requested" box for each privilege requested. Applicants have the burden
of producing information deemed adequate by the hospital for a proper evaluation of current
competence, current clinical activity, and other qualifications and for resolving any doubts related
to qualifications for requested privileges.
Department Chair: Check the appropriate box for recommendation on the last page of this form
and include your recommendation for focused professional practice evaluation (FPPE). If
recommended with conditions or not recommended, provide the condition or explanation on the
last page of this form.
Other requirements
 Note that privileges granted may only be exercised at the site(s) and/or setting(s) that
have sufficient space, equipment, staffing, and other resources required to support the
privilege.
 This document is focused on defining qualifications related to competency to exercise
clinical privileges. The applicant must also adhere to any additional organizational,
regulatory, or accreditation requirements that the organization is obligated to meet.
QUALIFICATIONS FOR OBSTETRICS AND GYNECOLOGY
Initial privileges: To be eligible to apply for privileges in obstetrics and gynecology (OB/GYN),
the applicant must meet the following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)—
or American Osteopathic Association (AOA)—accredited residency in OB/GYN.
AND
Current certification or active participation in the examination process leading to certification in
OB/GYN by the American Board of Obstetrics and Gynecology (ABOG) or the American Osteopathic
Board of Obstetrics and Gynecology.
AND
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Required current experience: At least 50 deliveries (including at least five C-sections) in the
past 12 months and the performance of at least 25 gynecological surgical procedures (including
at least five major abdominal cases), reflective of the scope of privileges requested, in the past 12
months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship
within the past 12 months.
Renewal of privileges: To be eligible to renew privileges in OB/GYN, the applicant must meet the
following criteria:
Current demonstrated competence and an adequate volume of experience (40 deliveries,
including at least 10 C-sections, and 20 gynecological surgical procedures, including at
least 10 major abdominal cases) with acceptable results, reflective of the scope of privileges
requested, for the past 24 months based on results of ongoing professional practice
evaluation and outcomes. Evidence of current physical and mental ability to perform
privileges requested is required of all applicants for renewal of privileges.
CORE PRIVILEGES: OBSTETRICS
☐ Requested Admit, evaluate, diagnose, treat, and provide consultation to adolescent and
adult female patients and/ or provide medical and surgical care of the female reproductive
system and associated disorders, including major medical diseases that are complicating
factors in pregnancy. May provide care to patients in the intensive care setting in
conformance with unit policies. Assess, stabilize, and determine the disposition of patients
with emergent conditions consistent with medical staff policy regarding emergency and
consultative call services. The core privileges in this specialty include the procedures on the
attached procedures list.
CORE PROCEDURES LIST
This is not intended to be an all-encompassing procedures list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this
organization.
TO THE APPLICANT: If you wish to exclude any procedures, please strike through the
procedures that you do not wish to request and then initial and date.
Obstetrics
 Performance of history and physical exam
 Amnioinfusion
 Amniocentesis
 Amniotomy
 Application of internal fetal and uterine monitors
 Augmentation and induction of labor
 Cesarean hysterectomy, cesarean section
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 Cerclage
 Cervical biopsy or conization of cervix in pregnancy
 Circumcision of newborn External version of breech
 Hypogastric artery ligation
 Immediate care of the newborn (including resuscitation and intubation)
 Interpretation of fetal monitoring
 Management of high-risk pregnancy, inclusive of such conditions as pre-eclampsia,
postdatism, third-trimester bleeding, intrauterine growth restriction, premature rupture of
membranes, premature labor, and placental abnormalities
 Management of patients with or without medical, surgical, or obstetrical complications for
normal labor, including toxemia, threatened abortion, normal puerperal patient, normal
antepartum and postpartum care, postpartum complications, and fetal demise
 Manual removal of placenta, uterine curettage
 Medication to induce fetal lung maturity
 Normal spontaneous vaginal delivery
 Obstetrical diagnostic procedures, including ultrasonography and other relevant imaging
techniques
 Operative vaginal delivery (including the use of obstetric forceps and/or the vacuum
extractor)
 Performance of breech and multifetal deliveries
 Pudendal and paracervical blocks
 Repair of fourth-degree perineal lacerations or of cervical or vaginal lacerations
 Treatment of medical and surgical complications of pregnancy
 Vaginal birth after previous cesarean section
CORE PRIVILEGES: GYNECOLOGY
 Requested Admit, evaluate, diagnose, treat, and provide consultation and the pre-, intra-, and
postoperative care necessary to correct or treat female patients of all ages presenting with
injuries and disorders of the female reproductive system and the genitourinary system and
nonsurgically treat disorders and injuries of the mammary glands. May provide care to
patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and
determine the disposition of patients with emergent conditions consistent with medical staff
policy regarding emergency and consultative call services. The core privileges in this specialty
include the procedures on the attached procedures list.
CORE PROCEDURES LIST
This is not intended to be an all-encompassing procedures list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this
organization.
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TO THE APPLICANT: If you wish to exclude any procedures, please strike through the
procedures that you do not wish to request and then initial and date.
Gynecology
 Performance of history and physical exam
 Adnexal surgery, including ovarian cystectomy, oophorectomy, salpingectomy, and
conservative procedures for treatment of ectopic pregnancy
 Aspiration of breast masses
 Cervical biopsy, including conization
 Colpocleisis
 Colpoplasty
 Colposcopy
 Cystoscopy as part of a gynecological procedure
 Diagnostic and therapeutic dilation and curettage
 Diagnostic and operative laparoscopy (other than tubal sterilization)
 Endometrial ablation
 Laparotomy (other than tubal sterilization)
 Gynecologic diagnostic procedures, including ultrasonography and other relevant imaging
techniques
 Hysterectomy, abdominal and vaginal, including laparoscopically assisted
 Hysterosalpingography
 Hysteroscopy, diagnostic or ablative, excluding the use of the resection technique
 Incision and drainage of pelvic abscesses
 Incidental appendectomy
 Metroplasty
 Myomectomy, abdominal
 Operation for treatment of early-stage carcinoma of the vulva, vagina, endometrium,
ovary, or cervix
 Operation for treatment of urinary stress incontinence, vaginal approach, retropubic urethral
suspension, and sling procedure
 Operation for uterine bleeding (abnormal and dysfunctional)
 Operations for sterilization (tubal ligation, transcervical sterilization [determine whether
core or non-core])
 Operative management of pelvic pain
 Diagnosis and management of pelvic floor dysfunction, including operations for its
correction (e.g., repair of rectocele, enterocele, cystocele, or pelvic prolapse)
 Tuboplasty and other infertility surgery (not microsurgical)
 Uterosacral vaginal vault fixation, paravaginal repair
 Uterovaginal, vesicovaginal, rectovaginal, and other fistula repair
 Vulvar biopsy
 Vulvectomy, simple
Acknowledgment of Practitioner
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I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform and for which I wish to exercise at Hurley Medical
Center. I also acknowledge that my professional malpractice insurance extends to all privileges I have
requested.
I understand that in exercising any clinical privileges granted, I am constrained by hospital and medical
staff bylaws, policies and rules applicable generally and any applicable to the particular situation.
Signed ________________________________________ Date _____________________
Department Chair Recommendation:
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and:
❑ Recommend all requested privileges
❑ Recommend privileges with the following conditions/modifications:
❑ Do not recommend the following requested privileges:
Privilege Condition/modification/explanation
Notes:
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Department Chair signature ________________________ Date _____________________
FOR MEDICAL STAFF USE ONLY
Credentials Committee action Date _____________________
Medical Executive Committee action Date _____________________
Board of Managers action Date _____________________