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DEPARTMENT OF SURGERY PLASTIC SURGERY

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					St. Vincent Medical Center Medical Staff Administration Delineation of Clinical Privileges

DEPARTMENT OF SURGERY PLASTIC SURGERY                                                                                                                                          page 1 of 3

 Practitioner Name Last/First/Middle Initial                                                                                      Telephone


                                                                             BASIC QUALIFICATIONS


         •    Basic Education MD or DO
         •    Minimal Formal Training Completion of an ACGME-approved residency in the identified specialty
         •    Board Certified or Board Qualified Applicants must be board certified or meet the requirements for obtaining board certification with education,
              training and experience as required by the board in their respective specialties; or, have successfully completed an accredited residency in the specialty
              in which they are requesting clinical privileges. The boards recognized to satisfy the above requirements are those approved by the American Board of
              Medical Specialties.
         •    Current Unrestricted State of California Medical License
         •    Malpractice Liability Coverage in the Amount of 1,000,000/3,000,000
         •    Required Previous Experience Performance of at least twenty-four (24) specialty-specific procedures as noted in the Qualifying Number column in
              the past two (2) years.
         •    Documentation must be submitted that supports the number listed in the column below titled Qualifying Number. For practitioners out of training less
              than two (2) years, a case log for the training period will be accepted. For practitioners out of training more than two (2) years, an activity report must be
              submitted from a hospital where you are currently most active documenting the type and number of procedures performed over the past two (2)
              calendar years.
         •    Reappointment is based on unbiased objective results of care according to Medical Staff’s quality management mechanisms. Applicants for
              reappointment must show that they have met identified thresholds for each privilege they request.

R - PRACTITIONER REQUESTED
 Adult       Peds                                                                                                                                        ADULT      ADULT         PEDS        PEDS
                                     SURGERY CATEGORY I PRIVILEGES                                     CRITERIA              Qualifying    Number
                                                                                                                                                        GRANTED     DENIED       GRANTED     DENIED
   R          R                                                                                                               Number      Past 2 Yrs




  □          □      Admit, evaluate, diagnose and perform surgical procedures for patients        See Basic Qualifications
                                                                                                                                                           □           □             □          □
                    presenting with both congenital and acquired defects of the body’s soft                                  12/YR
                    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; and cosmetic surgery.
R - PRACTITIONER REQUESTED
 Adult       Peds                                                                                                                                          ADULT      ADULT         PEDS        PEDS
                                     SURGERY CATEGORY II PRIVILEGES                                    CRITERIA              Qualifying     Number
                                                                                                                                                          GRANTED     DENIED       GRANTED     DENIED
   R          R                                                                                                               Number       Past 2 Yrs




  □          □      Privileges in this category allow the practitioner to assist only on cases    See Basic Qualifications   12/YR                          □          □             □          □
                    as indicated below.
St. Vincent Medical Center Medical Staff Administration Delineation of Clinical Privileges
DEPARTMENT OF SURGERY PLASTIC SURGERY PRIVILEGES                                                                                                                                   page 2 of 3

 Practitioner Name Last/First/Middle Initial                                                                                         Telephone



                                                                        Plastic Surgery Core Procedure Privilege List

Repair of traumatic defects requiring reconstructive                       Surgical treatment of acute burns
surgery                                                                    Surgical treatment of post-burn deformities
        a. maxillofacial region                                            Surgical treatment of malignancies of conditions prone to
        b. trunk and extremities, involving:                                    malignancy
           1. pedicle flaps                                                        a. head and neck region, including intra-oral
           2. skin grafts                                                          b. body and extremities
           3. bone, cartilage, fascia, tendon grafts                       Reconstructive surgery to the hand, including:
           4. use of alloplastic materials                                         a. surface surgery
Surgical treatment of maxillofacial fractures                                      b. surgery to bones, tendons, nerves and blood
        a. mandible                                                                      vessels
        b. maxilla                                                         Treatment of congenital anomalies
        c. zygomatic bone complex                                                  a. syndactylism
        d. orbit                                                                   b. congenital absence – partial or total of external ear
        e. nose                                                                    c. hypospadias
Aesthetic surgery of:                                                              d. thyroglossal duct cysts
        a. Rhytidectomy (face lift)                                                e. extensive nevi
        b. blepharoplasty                                                          f. congenital bands
        c. otoplasty                                                               g. congenital absence of vagina
        d. rhinoplasty and submucous resection                             Surgical treatment of complications of surgery, either:
        e. breast                                                                  a. iatrogenic
           1. reduction mammoplasty                                                b. unexpected
           2. Augmentation mammoplasty
        f. aesthetic surgery to abdomen and buttocks
R - PRACTITIONER REQUESTED
 Adult     Peds
   R        R                                                   PROCEDURAL SEDATION                                                    ADULT
                                                                                                                                       GRANT
                                                                                                                                               ADULT
                                                                                                                                               DENIED
                                                                                                                                                         PEDS
                                                                                                                                                        GRANT
                                                                                                                                                                      PEDS
                                                                                                                                                                     DENIED



  □         □     Procedural Sedation
                                                                                                                                        □        □       □            □
                  Applicant must complete review of all Procedural Sedation Study Guide materials, including
                  completing an examination with a minimum score of eighty percent (80%)
R - PRACTITIONER REQUESTED        A - ASSIST ONLY

 R                                                                 FLUOROSCOPY PRIVILEGES                                                                    GRANT        DENIED




 □       Applicant must have a current X-Ray Operator’s license                                                                                              □             □
St. Vincent Medical Center Medical Staff Administration Delineation of Clinical Privileges
DEPARTMENT OF SURGERY PLASTIC SURGERY PRIVILEGES                                                                                                                                                 page 3 of 3

 Practitioner Name Last/First/Middle Initial                                                                                                             Telephone




                                                                                 ACKNOWLEDGEMENT OF APPLICANT

 I have requested only those clinical privileges for which my education, training, current experience and documented performance supports that I am qualified to perform at St. Vincent
 Medical Center; and, I understand that
      •    in exercising any clinical privilege granted, I am constrained by generally applicable Hospital and Medical Staff policies and rules and any others applicable to the particular situation; and,
      •    any restriction on those clinical privileges granted me is waived in an emergency situation and in any such situation where my actions are governed by the applicable section of the Medical Staff bylaws,
           rules or related documents.



 Practitioner Signature                                                                                                                                                Date


                                                                                                  APPROVALS

                     The resources necessary to support the above requested privileges re determined to be currently available.                                        Date

 Department of Surgery Chair or Section Chair Signature

                                                                          Medical Executive Committee                                       SVMC Board of Directors
                                                                          Approval                                                          Approval

				
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