DEPARTMENT OF RADIOLOGY
DELINEATION OF PRIVILEGES
Includes Teleradiology, Diagnostic and Interventional, and Radiation Oncology
NAME:____________________________________________________DATE__________________
To be eligible to apply for privileges in diagnostic radiology, 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 diagnostic radiology.
TELERADIOLOGY
Not
Req.
Req.
TELERADIOLOGY PRIVILEGES AT MARGARETVILLE HOSPITAL
(These are the only privileges available at Margaretville Hospital)
Perform general diagnostic radiology (x-ray, radionuclides, ultrasound, and electromagnetic radiation)
to diagnose diseases of the patients of all ages via a teleradiography link. Responsible for
communicating critical values and critical findings consistent with medical staff policy. The core
privileges in this specialty include the procedures listed below and such other procedures that are
extensions of the same techniques and skills.
General Diagnostic (plain films)
Compterized Tomography
Diagnostic Ultrasound
Magnetic Resonance Imaging
Mammography
Not
Req.
Req.
TELERADIOLOGY PRIVILEGES AT BENEDICTINE & KINGSTON
Perform general diagnostic radiology (x-ray, radionuclides, ultrasound, and electromagnetic radiation)
to diagnose diseases of the patients of all ages via a teleradiography link. Responsible for
communicating critical values and critical findings consistent with medical staff policy. The core
privileges in this specialty include the procedures listed below and such other procedures that are
extensions of the same techniques and skills.
General Diagnostic (plain films)
Compterized Tomography
Diagnostic Ultrasound
Magnetic Resonance Imaging
Diagnostic Nuclear Medicine
Department of Radiology Privileges
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GENERAL DIAGNOSTIC RADIOLOGY PRIVILEGES FOR BENEDICTINE AND
KINGSTON HOSPITALS
Not
Req.
Req.
PRIVILEGES
General Diagnostic Radiology
Fluoroscopy Studies – GI, BE, etc.
Intravenous Contrast Exams IVP, IVC,
etc.
Ultrasonography
Vascular Lab.
Mammography
Nuclear Medicine
Magnetic Resonance Imaging
Performance of Invasive Diagnostic
Procedures
PRIVILEGES / COMMENTS
Other Privileges Requested (please list)
To be eligible to apply for privileges in vascular and interventional radiology, the initial applicant must meet the following
criteria:
Successful completion of an ACGME – or AOA accredited residency in diagnostic radiology, followed by completion of
a one-year accredited fellowship in vascular and interventional radiology AND/OR Current subspecialty certification or
active participation in the examination process (with achievement of certification within 3 years) leading to subspecialty
certification in vascular and interventional radiology by the American Board of Radiology or completion of a certificate of
added qualification in angiography and interventional radiology by the American Osteopathic Board of Radiology.
Not
Req.
Req.
PRIVILEGES
VASCULAR
Peripheral Angiography
Selective Visceral Angiography
Carotid and Vertebral Angiography
Pulmonary Angiography
Venography
Lymphography
PRIVILEGES / COMMENTS
Other Privileges Requested (please list)
Aortogram
Digital Subtraction Angiography
Arthrography
Hystero-salpinography
Myelography
Sialography
Needle Biopsies
Breast Needle Localization
Galactography
Department of Radiology Privileges
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Not
Req.
Req.
PRIVILEGES
PRIVILEGES / COMMENTS
INVASIVE THERAPEUTIC
PROCEDURES
Other Privileges Requested (please list)
Percutaneous Drainage of Fluid &
Abscesses
Nephrostomy & Stone Retraction
Biliary Drainage & Stone Retraction
Angioplasty
IVC Filter Insertion
Tumor Embolization
Thrombolysis
Stents
Conscious Sedation
RADIATION ONCOLOGY
To be eligible to apply for privileges in radiation oncology, 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 radiation oncology.
CORE PRIVILEGES (please cross out what does not apply): Admit, conduct comprehensive (multidisciplinary)
evaluation for, and provide consultation and treatment planning, including therapeutic applicants of radiant energy and its
modifiers, to patients of all ages with cancer (malignant and benign) and related disorders. 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 listed below and such other procedures that are extensions of the
same techniques and skills.
Not
Req.
Req.
PRIVILEGES
Performance of history and physical
exam
Administration of drugs and medicines
related to radiation oncology and cancer
supportive care
Administration of radiosensitizers and
radioprotectors under appropriate
circumstances
Brachytherapy, both interstitial and
intracavitary, and unsealed radionuclide
therapy (including/excluding) for the
breasts.
Combined modality therapy (e.g.,
surgery, radiation therapy,
chemotherapy, or immunotherapy used
concurrently or in a timed sequence)
Department of Radiology Privileges
PRIVILEGES / COMMENTS
Other Privileges Requested (please list)
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RADIATION ONCOLOGY – Continued
Not
Req.
Req.
PRIVILEGES
PRIVILEGES / COMMENTS
Computer-assisted treatment simulation
and planning (external beam therapy and
radioactive implants)
Fractionated stereotactic radiotherapy
Immunotherapy
Intraoperative radiation therapy
Interpretation of studies as they pertain
to neoplastic or benign conditions
Placement of catheters, IVs, IV contrast
dye, and radiopaque devices that pertain
to treatment planning
Radiation prescription of doses,
treatment volumes, field blocks,
molds, and other special devices for
external beam therapy
Radiation therapy by external beam
(photon and electron irradiation)
Radiation therapy and contact therapy
(SR, molds, etc.)
Radioactive isotope therapy, including
intraperitoneal, intracavitary, interstitial,
intraluminal implantation, regional and
systemic, and IV and radioactive
antibody therapy
Steroatactic radiosurgery (determine
whether core or non-core)
Total body irradiation
X-ray, ultrasound, computer
tomography, magnetic resonance
imaging, positron emission tomography,
and assisted treatment planning.
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 HealthAlliance facilities. I also request the ability to do any
procedure in an emergency situation.
Applicant’s Signature: ________________________________________ Date: ________________
I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and
recommend action on the privileges as noted above.
Department Chair’s Signature: ___________________________________Date: ________________
Broadway and Mary’s Avenue Campuses
Department of Radiology Privileges
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Department of Radiology Privileges
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