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PALMS OF PASADENA HOSPITAL
CLINICAL PRIVILEGE DELINEATION
ANESTHESIOLOGY
Practitioner’s Name ____________________________________________________________________________________
Core privileges describe care or procedures performed at the level of a fully trained and/or Board Certified specialist in Anesthesiology.
Care or procedures requiring additional or more specialized training or experience are delineated in supplemental privileges.
CORE PRIVILEGES
REQUESTED
APPROVED
GENERAL ANESTHESIOLOGY CORE PRIVILEGES
Management of patients rendered unconscious or insensible to pain and emotional stress during
surgical and certain other medical procedures; including preoperative, intraoperative and
postoperative evaluation and treatment; the support of life functions and vital organs under the stress
of anesthetic, surgical and other medical procedures; management of problems in pain relief,
cardiopulmonary resuscitation, pulmonary care, supervision of patients in post-anesthesia care units
and critically ill patients in special care units.
GENERAL REQUIREMENTS
1. EDUCATION
2. FORMAL TRAINING
3.
BOARD STATUS/OTHER
4.
REQUIRED PREVIOUS EXPERIENCE
SPECIFIC REQUIREMENTS
M.D. or D.O.; must be ACLS certified
Physicians applying for core privileges in General Anesthesiology must demonstrate evidence of successful
completion of an approved ACGME or AOA Anesthesia residency program.
All applicants/members shall be either Board certified or an Active Candidate for certification by the American
Board of Anesthesiology or an equivalent Anesthesiology certifying Board, and will have completed residency
training. All applicants/members must comply with the ABA Maintenance in Certification in Anesthesiology
Program (MCAP).
Initial Appointment: Each practitioner must be able to demonstrate that s/he has handled 350 general/
regional anesthesia cases in the past one-year period. An exception may be made, on an individual-casebasis.
Reappointment: Each practitioner must be able to demonstrate that s/he has handled 250 general/regional
anesthesia cases in a hospital setting during each 24-month period. If the practitioner has not performed the
sufficient number of cases at this hospital, s/he will be requested to provide appropriate documentation from
other area hospitals to demonstrate his/her current clinical competence.
Privileges falling outside the core set will require evidence of training, experience, and a successful practice pattern,
documented by the practitioner’s residency director and/or department chairman; or, documentation of successful completion of
an approved continuing education course that provided both didactic and hands-on instruction in the procedure requested.
INDICATE IF
SUPPLEMENTAL PRIVILEGES
PERFORMED IN
PAST 2 YRS
Management of problems in chronic pain relief by nonneurolytic regional
anesthetic techniques
 Yes
 No
Neurolytic blocks
 Yes
 No
 Yes
 No
Cryoneurolysis
 Yes
 No
Radiofrequency Neurolysis
 Yes
 No
Other:
 Yes
 No
REQUESTED
APPROVED
(Initially requires the performance of a minimum of five (5) procedures within the
past five-year period.)
Nerve stimulators and implantable narcotic pumps
(Completion of one-year Pain Management fellowship program or documented
evidence of performance of five (5) managed cases of each procedure.)
I apply for core privileges and/or supplemental privileges as requested above. I understand that in exercising clinical privileges, I
am constrained by the Medical Staff Bylaws/Rules and Regulations, and any restriction on the clinical privileges granted to me is
waived in an emergency situation and in such situation my actions are governed by the applicable section of the Bylaws and
Rules & Regulations. I certify that I am in good health and have no physical or mental limitation, including alcohol or drug use,
which could impair my ability to render quality patient care. I agree to abide by the ASA Guidelines for the Ethical Practice of
Anesthesiology.
Applicant’s Signature
Date
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PALMS OF PASADENA HOSPITAL
CLINICAL PRIVILEGE DELINEATION
Provider Name:
Specialty:
Department Chair Review
I have reviewed the provider’s application file along with supporting documentation including, the
requested clinical privileges, National Practitioner Data Bank report, primary source verification of
current state licensure, DEA, the results of quality assurance activities, practice profile, and health
status for the above-name applicant and make the recommendation(s) as indicated:




Recommend as requested
Recommend with modifications/conditions
Recommend deferral (requires further review)
Recommend denial
Privilege
Condition/Modification/Explanation
1.
2.
3.
Notes/Comments:
Department Chair;
Printed Name
Department Chair;
Signature
Committee
Credentials
Medical Council
Governing Board
Date
Action as Indicated in Minutes of Meeting












Recommend as requested
Recommend with modifications/conditions
Recommend deferral (requires further review)
Recommend denial
Recommend as requested
Recommend with modifications/conditions
Recommend deferral (requires further review)
Recommend denial
Approved as requested
Approved with modifications/conditions
Recommend deferral (requires further review)
Recommend denial
Meeting Date