Obstetrics & Gynecology Non-Core
Clinical Privileges
Name:
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Effective from
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☐Initial privileges (initial appointment)
to Click here to enter a date.
☐Renewal of privileges (reappointment)
Non-Core Privileges are requested individually in addition to requesting the core. Each individual
requesting non-core privileges must meet the minimum threshold criteria for the department of
Obstetrics & Gynecology.
☐NON-CORE PRIVILEGES: USE OF LASER
Initial privileges: Successful completion of an approved residency in a specialty or
subspecialty that included training in laser principles or completion of an approved 8 to 10
hour continuing medical education course that included training in laser principles. In
addition, an applicant for privileges should spend time after the basic training course in a
clinical setting with an experienced operator who has been granted laser privileges acting as a
preceptor. Practitioner agrees to limit practice to only the specific laser types for which he or
she has provided documentation of training and experience. The applicant must supply a
certificate documenting that he or she attended a wavelength and specialty-specific laser
course and also present documentation as to the content of that course.
AND
Completion of the “Laser Safety” Review and Exam with a score of 80% or greater.
AND
Required current experience: Demonstrated current competence and evidence of the
performance of use of laser in the past 12 months or completion of training in the past 12
months.
Renewal of privileges: Demonstrated current competence and evidence of the performance of
use of laser in the last 24 months based on results of ongoing professional practice evaluation and
outcomes.
Obstetrics & Gynecology Non-Core
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Clinical Privileges
☐NON-CORE PRIVILEGES: USE OF ROBOTIC ASSISTED SYSTEM FOR
GYNECOLOGIC PROCEDURES
Initial privileges: See Obstetrics & Gynecology Robotic Surgical Platform Clinical Privileges for
privileging requirements.
Renewal of privileges: See Obstetrics & Gynecology Robotic Surgical Platform Clinical Privileges
for privileging requirements.
☐NON-CORE PRIVILEGES: TRANSCERVICAL STERILIZATION
Initial privileges: Successful completion of an ACGME or AOA postgraduate training program
in OB/GYN and successful completion of a training program course in the transcervical
sterilization system for which the applicant is seeking privileges.
AND
Required current experience: Demonstrated current competence and evidence of at least 5
transcervical sterilization procedures in the past 12 months or completion of training in the past
12 months.
Renewal of privileges: Demonstrated current competence and evidence of at least 10
transcervical sterilization procedures in the past 24 months based on ongoing professional
practice evaluation and outcomes. In addition continuing medical education related to
transcervical sterilization is required.
☐NON-CORE PRIVILEGES: ADMINISTRATION OF MODERATE SEDATION &
ANALGESIA
Initial privileges: See Standard Practice 6907 “Moderate Sedation & Analgesia (Conscious
Sedation) Credentialing – Medical Staff” for privileging requirements.
Renewal of privileges: See Standard Practice 6907 “Moderate Sedation & Analgesia (Conscious
Sedation) Credentialing – Medical Staff” for privileging requirements.
Obstetrics & Gynecology Non-Core
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Clinical Privileges
Acknowledgment of Practitioner
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:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Department Chair signature ________________________ Date _____________________
FOR MEDICAL STAFF USE ONLY
Credentials Committee action Date _____________________
Medical Executive Committee action Date _____________________
Board of Managers action Date _____________________