Name:
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Pathology Privileges
Group 7
7.00
Pathology Core Privileges
Qualifications - to be eligible to apply for core privileges in pathology, the applicant must meet
the following qualifications:

Demonstration of the provision of pathology services during the past 24 months;
And


7.01
Current certification or active participation in the examination process leading to certification
in clinical and/or anatomic pathology by the American Board of Pathology or the American
Osteopathic Board of Pathology (if required by contract or hospital policy); or
Successful completion of an ACGME- or AOA-accredited residency in clinical and anatomic
pathology or a subspecialty of pathology.
Anatomic Core Privileges - Examination of body tissue or organs, including: general anatomical,
autopsy, cytopathology, and surgical pathology.
☐Requested
☐ Recommended
☐ Not Recommended
☐ Recommended with the following modification(s) and reason(s):
Please click here to enter recommended modifications and reasons.
7.02
Clinical Core Privileges - Examination of blood, urine and other body fluids to determine the
status of patients and to help in the diagnosis of diseases, including: microbiology, clinical
chemistry, immunology, blood banking, coagulation, and hematology.
☐Requested
☐ Recommended
☐ Not Recommended
☐ Recommended with the following modification(s) and reason(s):
Please click here to enter recommended modifications and reasons.
7.03
Special Procedures Privileges (see qualifications and/or specific criteria listed on page 2
and 3)
To be eligible to apply for a special procedure privilege listed below, the applicant must
demonstrate successful completion of an approved and recognized course or acceptable
supervised training in residency, fellowship, or other acceptable experience; and provide
documentation of competence in performing that procedure consistent with the criteria set forth
in the medical staff policies governing the exercise of specific privileges.
Pathology Core Privileges
Page 1 of 3
rev 09/07
Procedure
Criteria
Requested
Initial application: Successful
performance of  6 procedures in
past 12 months
Continued competence:
Successful performance of 12
☐
procedures in past 24 months
Or
Demonstration of competence
under the supervision of a
qualified member of the medical
staff
Fine needle
Initial application: Successful
aspiration of
performance of  6 procedures in
superficial masses
past 12 months
(not under CT
Continued competence:
guidance)
Successful performance of 12
☐
procedures in past 24 months
Or
Demonstration of competence
under the supervision of a
qualified member of the medical
staff
☐ Recommended with the following modification(s) and reason(s):
Please click here to enter recommended modifications and reasons.
Recommended
Not
Recommended
☐
☐
☐
☐
Bone marrow
aspiration/biopsy
Forensic Pathology – investigate and evaluate cases of sudden, unexpected, suspicious, and
violent death as well as other specific classes of death defined by law, including performing
medico-legal autopsies. This privilege includes bedside evaluation/consultation of an injured or
abused medico-legal patient as required by law or in the judgment of law enforcement or
attending/consulting physician.
(Requirements – successful completion of postgraduate training that included training in
forensic pathology and/or subspecialty certification in forensic pathology. At Hurley Medical
Center, an individual applying for this privilege is limited to the individual employed by or
contracted with the Genesee County Health Department and Genesee County Board of
Commissioners.)
☐Requested
☐ Recommended
☐ Not Recommended
☐ Recommended with the following modification(s) and reason(s):
Please click here to enter recommended modifications and reasons.
Pathology Core Privileges
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rev 09/07
Acknowledgement of Practitioner
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform, and that I wish to exercise at Hurley
Medical Center, and I understand that: (a) In exercising any clinical privileges granted, I am
constrained by hospital and medical staff policies and rules applicable generally and any
applicable to the particular situation. (b) Any restriction on the clinical privileges granted to me is
waived in an emergency situation and in such a situation my actions are governed by the
applicable section of the medical staff bylaws or related documents.
Signed: ____________________________________________
Date______________________
Department Chair’s Recommendation
I have reviewed the requested clinical privileges and supportive documentation for the above
named applicant and recommend action on the privileges as noted above.
Signed: ____________________________________________
Date______________________
Credentials Committee Approval
Date______________________
Executive Committee Approval
Board Approval
Date______________________
Date______________________
Pathology Core Privileges
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rev 09/07