DECATUR COUNTY MEMORIAL HOSPITAL
CLINICAL PRIVILEGES IN PHYSICAL MEDICINE & REHABILITATION
NAME:_________________________________________DATE:__________________
QUALIFICATIONS: To be eligible for core privileges in Physical Medicine & Rehabilitation, the
practitioner must meet the following qualifications:
BASIC EDUCATION: M.D. or D.O.
MINIMAL FORMAL TRAINING: Completion of an Accreditation Council for Graduate
Medical Education (ACGME) or American Osteopathic Association (AOA) accredited postgraduate training program in Physical Medicine & Rehabilitation.
CERTIFICATION: Physical Medicine & Rehabilitation requires current certification in ACLS.
EXPERIENCE: Applicants for initial appointment may be requested to provide documentation of
the number and types of cases for the past 24 months. Applicants have the burden of producing
information deemed adequate by the hospital for a proper evaluation of current competence and
other qualifications.
REAPPOINTMENT REQUIREMENTS: Basic Life Support competence, current demonstrated
competence and an adequate volume of current experience (as specified in the ADMINISTRATION
Medical Staff Credentialing Process) with acceptable results in the privileges requested for the past
24 months based on results of quality assessment/improvement activities and outcomes. Evidence
of current ability to perform privileges requested is required of all applicants for renewal of
privileges.
Note: If any privileges are covered by an exclusive contractual arrangement, physicians who are not party to the
contract are not eligible to request the privilege(s) regardless of education, training and experience.
CORE PRIVILEGES
Requested
Evaluate, diagnose and provide consultation and nonsurgical treatments to inpatients
and outpatients of all ages, except specifically excluded from practice, with physical
impairments and/or disabilities involving neuromuscular, neurological, cardiovascular,
or musculoskeletal disorders to include:
physical examination of
pain/weakness/numbness syndromes (both neuromuscular and musculoskeletal) with a
diagnostic plan and/or prescription for treatment that may include the use of physical
agents and/or other interventions: and evaluation, prescription, and supervision of
medical and comprehensive rehabilitation goals and treatment plans. Includes the use of
therapeutic exercise and physical modalities; prosthetics, orthotics and the use of other durable
medical equipment; gait analysis; diagnostic and therapeutic injections, electrodiagnostic
studies; and rehabilitation management.
SPECIAL NON-CORE PRIVILEGES
Pain Management: Basic Education: MD or DO; Minimal Formal Training: Completion of
Requested
an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic
Association (AOA) accredited post-graduate training program in Anesthesiology, Physical
Medicine and Rehabilitation, or Psychiatry and Neurology and a fellowship in Pain Medicine;
or other formal training and experience equivalent to that received in such a post graduate
training program. Pain Management Core Privileges: Evaluate, diagnose, treat and provide
consultation to patients with acute and chronic pain syndromes, including cancer pain
problems. Acupressure, behavior modification, broad range of peripheral nerve block
procedures, electrical stimulation techniques, radiofrequency, neuro stimulators,
epidural and subarachnoid injections, epidural, subarachnoid or peripheral neurolysis,
joint and bursal sac injection, modality therapy and physical therapy, peripheral
neurectomy and neurolysis. A practitioner, within the scope of his/her field of expertise, is
allowed to make a diagnosis based on preliminary interpretation of diagnostic testing and guide
treatment.
Requested
Requested
Requested
Requested
Requested
SPECIAL NON-CORE PAIN MANAGEMENT PRIVILEGES
Implanted Epidural and Intrathecal Catheters, Ports and Infusion Pumps
 Must provide documentation of training, list of procedures or other documentation
to determine competency
Fluoroscopy
 Supervision of fluoroscopic procedures – Must complete the Fluoroscopic Radiation
Safety Review and score at least 80% on the post test for initial privileges. If
physician has supervised ten fluoroscopic procedures over a twelve month period
following initial credentialing, then credentialing will automatically be granted at
time of reappointment.
Insertion of Spinal Cord Stimulators
 Must provide documentation of training, list of procedures or other documentation
to determine competency
Acupuncture
 Must provide documentation of training, list of procedures or other documentation
to determine competency
Moderate (Conscious) Sedation: Must maintain Basic Life Support Competency and
complete the DCMH Sedation & Analgesia open book test reviewing the DCMH
guidelines and education material with at least 100% score for initial credentialing. If
the physician has performed eight (8) or more cases at DCMH without complications
within the two (2) year credentialing period, renewal credentialing will occur
automatically at the time of reappointment.
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 Decatur County
Memorial Hospital.
Signed:_________________________________________Date:____________________


Found qualified for privileges requested.
Modifications recommended as follows:_________________________________
_________________________________________________________________
_________________________________________________________________
___________________________________________
Department Chair
Core Privilege Form Approved:
Department Committee
Medical Staff
Board of Trustees
Date: 11-14-14
Date: 06-03-15
Date: 06-25-15
__________________
Date