GARFIELD MEDICAL CENTER by S888vInM

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									            DELINEATION OF CLINICAL PRIVILEGES
                 DEPARTMENT OF SURGERY
                    PLASTIC SURGERY


NAME_______________________________________________________________


REQUESTED   GRANTED
                      PLASTIC SURGERY CORE


                          Documentation of the performance of 20 plastic
                           surgery procedures during the last two years, or
                           successful completion of an Accreditation Council for
                           Graduate Medical Education-approved residency or
                           clinical fellowship in the last two years, AND

                          Current certification or active participation in the
                           examination process leading to certification in plastic
                           and/or reconstructive surgery by the American Board
                           of Plastic Surgery or the American Osteopathic
                           Board of Surgery, OR

                          Successful completion of an Accreditation Council
                           for Graduate Medical Education - approved
                           residency in plastic and reconstructive surgery.

                      PRIVILEGES: Admit, evaluate, diagnose, consult and
                      perform surgical procedures for adult patients (except as
                      specifically excluded from practice and except for those
                      special procedure privileges listed below) presenting with
                      both congenital and acquired defects of the body’s soft
                      tissue, including the provision of consultation.        Core
                      privileges include treatment of skin neoplasia; diseases and
                      trauma; surgery of the breast, including breast
                      reduction/augmentation      and     breast     reconstruction;
                      treatment of facial diseases and any injuries including
                      maxillofacial structures; reconstruction of congenital and
                      acquired defects of the trunk and genitalia; liposuction; and
                      cosmetic surgery.
PRIVILEGE DELINEATION
DEPARTMENT OF SURGERY
PLASTIC SURGERY
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                           SURGICAL ASSISTANT
                            Documentation of training and/or experience in assisting
                             privileges. Physicians granted privileges to perform a
                             requested procedure shall automatically be approved to
                             assist at the same time.

                           SPECIAL PROCEDURE PRIVILEGES
                           QUALIFICATIONS -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 granting of clinical
                           privileges.
REQUESTED     GRANTED      PROCEDURE


                           Endoscopic carpal tunnel release
                           Replantation surgery
                           Administration of conscious sedation
                           OTHER (list)




PRIVILEGES TO PRESCRIBE MEDICATIONS
 Physicians with a current and valid DEA certificate will be granted the privilege of
  prescribing medications, except as restricted in accordance with policies of the
  Pharmacy Department.




APPLICANT’S NAME__________________________________________________
PRIVILEGE DELINEATION
DEPARTMENT OF SURGERY
PLASTIC SURGERY
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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 Garfield Medical Center. 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 the applicable section of the medical staff bylaws
       governs my actions or related documents.



APPLICANT’S SIGNATURE                                                 Date


DEPARTMENT CHAIR’S RECOMMENDATIONS


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 of Surgery Chairman                                        Date




______________________________________________________________________
Medical Executive Committee                      Date


(form approved by Department of Surgery on 3/12/04;4/12/10;8/11/10)
rac\\c:\my docs\rules\privilege form.surgery.plastic surgery




APPLICANT’S NAME__________________________________________________

								
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