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					                        Supplement to the Application for Appointment to the Medical Staff
                                                 DELINEATION OF PRIVILEGES
                                                         DEPARTMENT OF MEDICINE

I,_____________________________________, am applying for privileges for the following diagnostic and
     (Applicant's Name)                                  therapeutic procedures:

Please check only those procedures, regardless of sub-specialty, you wish to perform. If you check procedures listed under a subspecialty
for which you are not certified or board eligible, you will be expected to provide documentation of your training and experience performing
the procedure.




□ Privileges to admit, evaluate, diagnose and provide non-surgical treatment within the scope of General Internal Medicine to patients
in need of care in the hospital or outpatient clinic setting. These privileges do not include any of the following special requests.
I further understand that as a member of the Medical Staff, I shall, in an emergency, be authorized to treat any medical diseases
and/or perform any medical or surgical procedures indicated. An emergency, for these purposes, is defined as any situation in which
any delay in administering treatment would result in serious harm to the patient or an immediate threat to the life of the patient.


Department of Medicine Credentialing documentation

       Division                         Procedure                                                                                   SITE
                                                                                                                        UH       TKC EXT      UABH
       Internal Medicine
       Internal Medicine                Arterial puncture for blood gas analysis sample
       Internal Medicine                Arthrocentesis
                                        Central venous line placement, percutaneous or cutdown
       Internal Medicine                (emergency -----, or elective-----)
       Internal Medicine                Lumbar puncture
       Internal Medicine                Nasogastric intubation
       Internal Medicine                Thoracentesis, diagnostic or therapeutic
                                        Incision and drainage of abscess, lymph node, intracutaneous or
       Internal Medicine                subcutaneous lesion
       Internal Medicine                Skin scraping for culture
                                        Ablation of simple skin lesions using cryosurgery, electrocautery
       Internal Medicine                or other methods
                                        Anoscopy with or without related diagnostic and therapeutic
       Internal Medicine                procedures
       Internal Medicine                Endometrial aspiration biopsy of uterus lining
       Internal Medicine                Skin biopsy and excision
       Internal Medicine                Suture of skin laceration
       Internal Medicine                Lavage of external auditory canal
       Internal Medicine                Cardiopulmonary resuscitation
       Internal Medicine                Percutaneous needle biopsy of peritoneum
       Internal Medicine                Urine analysis including microscopic exam
                                        Microscopic evaluation of specimens for the diagnosis of
                                        infectious diseases including specimen preparation (e.g., blood,
                                        sputum, CSF, needle aspirates, vaginal smears, and exudates),
                                        staining (e.g., Giemsa, Gram, acid fast, toluidine blue, KOH/wet
       Internal Medicine                mount), and examination
       Internal Medicine                Mgmnt and/or care of indwelling vascular access catheters
       Internal Medicine                Urinary bladder catheterization
       Internal Medicine                Bone marrow aspiration and biopsy
       Internal Medicine                Therapeutic phlebotomy
       Internal Medicine                Proctoscopy and/or sigmoidoscopy, rigid or flexible
       Internal Medicine                Advanced cardiac life support
       Internal Medicine                Perform and interpret electrocardiograms
Division                 Procedure                                                                       SITE
                                                                                                 UH   TKC EXT   UABH
Internal Medicine        Subclavian catheter placement
Internal Medicine        Pericardiocentesis, therapeutic (emergency)
                         Peritoneocentesis, abdominal paracentesis, or peritoneal lavage
Internal Medicine        (diagnostic or therapeutic)
Internal Medicine                         Administration of oxygen therapy
                             Administration of therapeutic agents and biological products
Internal Medicine                            through all therapeutic routes
                              Nasal or orotracheal intubation, with or without fiber optic
Internal Medicine                                     instruments
Internal Medicine        Graded exercise testing/ECG
Internal Medicine        Transiliac bone biopsy
Internal Medicine        Interpretation of dual-energy x-ray absorptiometry studies
Internal Medicine        Institution and maintenance of ventilator supported breathing
Internal Medicine        Insertion, change and/or management of tracheostomy tubes
Internal Medicine        Performance of simple spirometry
                         Diagnostic aspiration of and/or analysis by light and polarized
                         light microscopy of synovial fluid from diarthroidial joints, bursae,
Internal Medicine        tenosynovial structures, ganglion or cyst
                         Therapeutic injection of diarthroidial joints, bursae, tenosynovial
                         structures, ligaments, ganglion, cyst or trigger points
Internal Medicine
                         Percutaneous aspiration of abscess, hematoma, bulla or cyst, deep
Internal Medicine        tissue
Internal Medicine        Wound debridement
Internal Medicine        Conscious sedation

Allergy
                         Performance and interpretation of allergy skin tests (prick and
Allergy                  intradermal)
Allergy                  Fiberoptic rhinolaryngoscopy
Allergy                  Prescription & administration of allergy desensitization therapy

Cardiovascular Disease
General                  Systemic arterial insertion, percutaneous or cutdown
General                  Cardioversion, elective
General                  Pericardiocentesis, diagnostic, elective
General                  Conscious sedation ( Could be in many other areas)

                         Supervision, performance, & interpretation of cardiovascular
Non-invasive Imaging     magnetic resonance imaging scans
                         Supervision, performance, & interpretation of cardiovascular
Non-invasive Imaging     radionuclide scans
                         Supervision, performance, & interpretation of transthoracic
Non-invasive Imaging     echocardiograms
                         Supervision, performance, & interpretation of transesophageal
Non-invasive Imaging     echocardiograms
                         Supervision, performance, & interpretation of stress (exercise,
Non-invasive Imaging     pacing, and pharmacologic) echocardiograms

Cardiographics           Supervision, performance, & interpretation of stress tests
                         Supervision, performance, & interpretation of ambulatory
Cardiographics           monitoring
Cardiographics           Supervision, performance, & interpretation of tilt table testing
                         Supervision, performance, & interpretation of permanent
Cardiographics           pacemaker follow-up studies
Division                    Procedure                                                                    SITE
                                                                                                 UH   TKC EXT   UABH
                            Supervision, performance, & interpretation of implantable
Cardiographics              cardioverter/defibrillator follow-up studies

                            Cardiac electrophysiological studies including mapping,
Electrophysiology lab       percutaneous or assisting intraoperative
Electrophysiology lab       Electrophysiologic cardiac ablation procedures
                            Supervision, performance, & implantation of permanent cardiac
Electrophysiology lab       pacemakers
                            Supervision, performance, & implantation of implantable
Electrophysiology lab       cardioverter/defibrillators
Electrophysiology lab       Extraction of pacemaker and ICD leads and generators

Cardiac Cath lab and/or
                            Supervision, insertion, and management of temporary cardiac
bedside in intensive care
                            pacemaker
units
Cardiac Cath lab and/or
                            Supervision, performance, & interpretation of right and left heart
bedside in intensive care
                            catheterization, with and without angiography
units
Cardiac Cath lab and/or
                            Supervision, insertion, and management of intraaortic balloon
bedside in intensive care
                            counterpulsation devices
units
Cardiac Cath lab and/or
                            Supervision, insertion, and management of chronic indwelling or
bedside in intensive care
                            implanted electronic hemodynamic monitoring devices
units
Cardiac Cath lab and/or
                            Supervision, insertion, and management percutaneous
bedside in intensive care
                            cardiopulmonary support cannulae
units
Cardiac Cath lab and/or
                            Supervision and performance of cerebrovascular, thoracic,
bedside in intensive care
                            abdominal, pelvic, and extremity arterial and venous angiography
units
Cardiac Cath lab and/or
                            Supervision and performance of percutaneous endomyocardial
bedside in intensive care
                            biopsy
units
Cardiac Cath lab and/or
                            Supervision and performance of transseptal left heart
bedside in intensive care
                            catheterization
units
Cardiac Cath lab and/or
                            Supervision, performance, & interpretation of intravascular
bedside in intensive care
                            ultrasound procedures
units
Cardiac Cath lab and/or
                            Supervision, insertion, and management if selective arterial or
bedside in intensive care
                            venous infusion/injection of thrombolytic agents
units

                          Supervision, performance, & interpretation of percutaneous
Interventional Cardio Lab angioplasty of coronary arteries, with and without stents
                          Supervision, performance, & interpretation of percutaneous
Interventional Cardio Lab angioplasty of carotid arteries, with and without stents
                          Supervision, performance, & interpretation of percutaneous
Interventional Cardio Lab angioplasty of renal arteries, with and without stents
                          Supervision, performance, & interpretation of percutaneous
                          angioplasty of abdominal (non-renal) arteries, with and without
Interventional Cardio Lab stents
                          Supervision, performance, & interpretation of percutaneous
                          angioplasty of pelvic, and extremity arteries (upper and lower),
Interventional Cardio Lab with and without stents
Division                    Procedure                                                                      SITE
                                                                                                   UH   TKC EXT   UABH
                            Supervision, performance, & interpretation of percutaneous
                            angioplasty of pelvic, and extremity veins, with and without stents,
Interventional Cardio Lab   to gain central access
                            Supervision, performance, & interpretation of atherectomy of
Interventional Cardio Lab   coronary arteries by laser, directional, or rotational methods
                            Supervision, performance, & interpretation of atherectomy of
                            abdominal, pelvic, and extremity veins and arteries by laser,
Interventional Cardio Lab   directional, or rotational methods
                            Supervision, performance, & interpretation of peripheral arterial
Interventional Cardio Lab   thrombectomy
                            Supervision, performance, & interpretation of balloon
Interventional Cardio Lab   valvuloplasty of cardiac valves

Endocrinology &
Metabolism
Endocrin & Metabolism       Percutaneous needle aspiration/biopsy of thyroid
Endocrin & Metabolism       Insulin tolerance test

Gastroenterology &
Hepatology
                            Diagnostic and therapeutic upper gastrointestinal endoscopy, with
                            or without other therapeutic and diagnostic related procedures
GI & Hepatology
                            Colonoscopy, including biopsy and polypectomy, with or without
GI & Hepatology             related diagnostic and therapeutic procedures
GI & Hepatology             Endoscopic Retrograde Colangio pancreatography(ERCP)
GI & Hepatology             Endoscopic Ultrasound (EUS)
GI & Hepatology             Esophageal dilation
GI & Hepatology             Percutaneous needle liver biopsy
                            Percutaneous endoscopic gastrostomy or jejunostomy; changing of
GI & Hepatology             gastrostomy tube
GI & Hepatology             Chemical destruction or cautery desiccation of anal lesions
GI & Hepatology             Incision of thrombosed hemorrhoid
GI & Hepatology             Injection sclerosis, banding of hemorrhoids
GI & Hepatology             Incision and drainage of perirectal and/or perianal abscess
                            Insertion of intraperitoneal cannula or catheter for drainage of
GI & Hepatology             ascites
GI & Hepatology             Conscious sedation
GI & Hepatology             Small intestine enteroscopy
                            Percutaneous endoscopic retrograde cholangiography with stone
GI & Hepatology             extraction, sphincterotomy, stent placement
                            Flexible endoscopic examination of swallowing and sensory
GI & Hepatology             testing with a thin nasopharyngeal-esophagoscope
GI & Hepatology             24-hr intraesophageal or gastric pH monitoring
GI & Hepatology             Hypophayrngeal-esophageal manometry

Gerontology & Geriatric
Medicine
                            Performance and interpretation of ultra-sound of bladder for post-
Gerontology                 void residual urine
Gerontology                 Performance and interpretation of cystometrogram
Gerontology                 Performance and interpretation of electromyography
Gerontology                 Performance and interpretation of anal and vaginal manometry
Gerontology                 Performance and interpretation of nerve conduction studies
Gerontology                 Bladder/sphincter biofeedback
Gerontology                 Hospice and palliative care
Division                     Procedure                                                                      SITE
                                                                                                    UH   TKC EXT   UABH

Palliative Medicine
Skills
Palliative Medicine skills   Interdisciplinary Team Leadership
Palliative Medicine skills   Home Hospice Medical Case Supervision
Palliative Medicine skills   Palliative Medicine Consultation
Palliative Medicine skills   Inpatient Palliative Medicine
Palliative Medicine skills   Pain Management
Palliative Medicine skills   Other (Non-Pain) Symptom Management
Palliative Medicine skills   Comprehensive Palliative Care Assessment
Palliative Medicine skills   Psychosocial, Spiritual, and Bereavement Assessment
Palliative Medicine skills   Other (specify): ____________________
Palliative Medicine skills   Other (specify): ____________________

Palliative Medicine
Procedures
Pall Med Procedures          Paracentesis
Pall Med Procedures          Thoracentesis
Pall Med Procedures          Management of Feeding Tubes
Pall Med Procedures          Management of Tracheostomy Tubes
Pall Med Procedures          Comfort Sedation
Pall Med Procedures          Family Conferences
                             Insertion of infusion therapy lines – (subcutaneous, intravenous)
Pall Med Procedures
Pall Med Procedures          Other (specify): ____________________
Pall Med Procedures          Other (specify): ____________________

Clinical Nutrition
Clinical Nutrition           Interpretation of indirect calorimetry studies
Clinical Nutrition           Formulation of parental nutrition solutions
Clinical Nutrition           Prescription of enteral feeding regimens
Clinical Nutrition           Interpretation of DEXA scans

Hematology/Oncology
                             Measurement of complete blood count, including platelets and
                             white cell differential, using automated or manual techniques
Hematology/Oncology
                             Perform bone marrow transplantation: including collection and
                             processing of hematopoietic progenitor cells from blood and/or
                             bone marrow for bone marrow transplantation and other support
Hematology/Oncology          for bone marrow patients
Hematology/Oncology          Removal of Hickman catheter
Hematology/Oncology          Therapeutic paracentesis
                             Administration of chemotherapeutic agents and biologic response
Hematology/Oncology          modifiers (all therapeutic routes)
                             Interpretation of indirect calorimetry studies and biologic response
Hematology/Oncology          modifiers (all therapeutic routes)
                             Interpretation of peripheral blood or buffy coat smear, bone
Hematology/Oncology          marrow aspirate and bone marrow biopsy

Infectious Diseases          See Internal Medicine

Nephrology
                             Placement of temporary central venous access for hemodialysis
Nephrology                   and related uses
Division                 Procedure                                                                    SITE
                                                                                              UH   TKC EXT   UABH
                         Placement of subcutaneously tunneled central venous access, with
                         or without a subcutaneous reservoir for hemodialysis and related
Nephrology               procedures
                         Placement of percutaneous intravenous continuous catheters
Nephrology               (PICC lines)
Nephrology               Conscious sedation protocols
Nephrology               Percutaneous diagnostic bone biopsy of the iliac crest
                         Ultrasound localization and/or guidance of central venous catheter
Nephrology               placement
                         Removal of subcutaneously tunneled central venous access, with
Nephrology               or without a subcutaneous reservoir
                         Ultrasound localization of native kidneys for the purpose of
Nephrology               percutaneous renal biopsy
                         Ultrasound localization of transplanted kidney for the purpose of
Nephrology               percutaneous biopsy
Nephrology               Percutaneous biopsy of native kidneys
Nephrology               Percutaneous biopsy of transplanted kidney
                         Ultrasound guided percutaneous biopsy of native or transplanted
Nephrology               kidneys
Nephrology               Diagnostic ultrasonography of native or transplanted kidneys
Nephrology               Insertion and/or removal of peritoneal dialysis Catheter
                         Thrombolysis, either mechanical or pharmacological, of clotted
Nephrology               dialysis access
                         Fistulogram and percutaneous angioplasty of dialysis accesses in
Nephrology               the extremities
                         Stent placement following percutaneous angioplasty of dialysis
Nephrology               accesses in the extremities
                         Venous mapping of extremities for the purpose of constructing
Nephrology               dialysis access
Nephrology               Conscious sedation
                         Provision of acute and chronic dialysis, including peritoneal
Nephrology               dialysis
Nephrology               Provision of continuous renal replacement therapies
Nephrology               Continuous venovenous dialysis
                         Performance of hemodialysis, peritoneal dialysis, acute and
Nephrology               chronic with related procedures
                         Performance of CAVH, CAVHD, CVVHD and related procedures
Nephrology
Nephrology               Abdominal fat pad biopsy to diagnose amyloidosis


Pulmonary and Critical
Care Medicine
                         Placement of pulmonary artery balloon flotation catheter (Swan-
Pulmonary                Ganz)
Pulmonary                Calibration and operation of hemodynamic recording systems
Pulmonary                Thoracostomy tube insertion and management
                         Fiberoptic bronchoscopy and accompanying procedures (i.e.
                         bronchoalveolar lavage, bronchial biopsy, transbronchial lung
                         biopsy, transbronchial needle aspiration/biopsy, foreign body
Pulmonary                removal)
Pulmonary                Placement of endobronchial catheter for Brachytherapy
                         Endobronchial intubation and initiation/management of
Pulmonary                mechanical ventilation
Pulmonary                Conscious sedation
Pulmonary                Fiberoptic rhinolaryngoscopy
       Division                          Procedure                                                                            SITE
                                                                                                                    UH     TKC EXT   UABH
       Pulmonary                         Performance and interpretation of pulmonary function tests
                                         Perform and interpret progressive exercise (stress) testing, with or
       Pulmonary                         without exercise gas exchange studies
       Pulmonary                         Initiation and management of CPAP and BiPAP therapy
       Pulmonary                         Performance and interpretation of indirect calorimetric studies
                                         Performance and interpretation of inhalation challenge tests,
       Pulmonary                         specific and non-specific
       Pulmonary                         Systemic arterial cannula insertion, percutaneous or cutdown
       Pulmonary                         Subclavian or jugular catheter placement
       Pulmonary                         Cardioversion (elective)
                                         Insertion and management of temporary cardiac pacemaker
       Pulmonary                         (emergency)
       Pulmonary                         Interpretation of chest radiographs
       Pulmonary                         Percutaneous needle aspiration of lung
       Pulmonary                         Pulmonary angiography
       Pulmonary                         Placement of vena cava filter
                                         Insertion and management of transtracheal oxygen therapy system
       Pulmonary
       Pulmonary                         Percutaneous needle pleural biopsy
       Pulmonary                         Chemical pleurodesis
       Pulmonary                         Insertion and removal of tracheostomy button
       Pulmonary                         Thoracoscopy with or without biopsy
       Pulmonary                         Transtracheal aspiration
       Pulmonary                         Laser therapy of tracheobronchial lesions
                                         Performance and interpretation of polysomnographic sleep studies
       Pulmonary

       Rheumatology
                                         Arthroscopy diagnostic (with or without synovial biopsy) or
       Rheumatology                      therapeutic (with or without tidal lavage)
       Rheumatology                      Percutaneous needle biopsy of joint (knee or other joint)

       List Other Procedures             Please be specific




Signature of Applicant _________________________________________________ Date _________________

FOR DIVISION/DEPARTMENT ACTION:


Approval:        □ as requested          □ as modified, explain ________________________________________________
                                                              _________________________________________________
                                                              _________________________________________________


Justification:   □ board certification        □   proficiency demonstrated     □ outside experience verified and on file

____________________________________________________               _________________________________________________
Approval Signature: Division Director                     Date      Department Chairperson                                 Date

				
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posted:4/9/2011
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