[YOUR MEDICAL CENTER NAME HERE]
DELINEATION OF PRIVILEGES IN ABORTION PROCEDURES
DEPARTMENT OF FAMILY MEDICINE
NAME:
M.D./D.O.
(Print)
(Circle One)
Family Physicians requesting privileges in abortion procedures need to meet the following requirements:
1.
Current member of the Department of Family Medicine in good standing.
2.
Documentation of training in abortion procedures by a recognized training program. Recognized are listed below.*
3.
Maintaining these privileges requires providing the department with regular reports for the Departments Quality Improvement
Program.
I. Manual Vacuum Aspiration (MVA)
Physicians requesting these privileges must provide documentation of a minimum of 50 MVAs. Privileges for this procedure will be
granted only after the physician has performed 2 successful procedures under the direct supervision of a physician designated by this
Department’s Chair.
II. Using Ultrasonography in the Assessment of Medication Abortions.
Physicians requesting this procedure must provide documentation of a minimum of 30 Ultrasound exams. These limited study
sonograms need to include the dating of the first trimester of the pregnancy and follow up of early spontaneous or induced abortions.
Physicians will be observed for the performance of a minimum of 2 sonograms by an appropriately designated physician. Granting this
privilege is subject to the review of the Department Chair.
LIST OF PROCEDURES
Requested
Privileges
# of Procedures
Complications
(list total #)*
Supervised
Procedures (2)
Privileges Approved
(Dept. only)
Manual Vacuum
Aspiration
Limited Study
Ultrasonography
_______________________________________
Signature of Family Physician
Date
_______________________________________
Signature of Supervising Physician
Date
_______________________________________
Signature of Chair Department of Family Medicine
Date
** Recognized training programs:
1. Fellowship in Reproductive Health.
2. Clinical training program of [fill in name of site here, such as local Planned Parenthood or other established training program]
www.reproductiveaccess.org