Download Medicine - Renown Health

Revised: 1/2005
RENOWN SOUTH MEADOWS MEDICAL CENTER
DEPARTMENT OF MEDICINE
DELINEATION of PRIVILEGES
To be eligible to request initial core clinical privileges, in the Department of Medicine, at Renown South
Meadows Medical Center, an applicant must meet the following minimum threshold criteria:
The Office location of the applicant will be sufficiently close to Renown South Meadows Medical Center to
provide continuity of care to patients as defined by the Medical Staff Policies and Procedures. Additionally,
the applicant must retain the same Medical Staff Status at Renown Regional Medical Center as those
requested at Renown South Meadows Medical Center.
The applicant must have actively practiced 18 of the last 24 months. The applicant must have actively
practiced in an accredited hospital 2 of the last 5 years.
Medical Doctor and Doctor of Osteopathic Medicine Qualification: Satisfactorily completed an ACGME
approved postgraduate residency training program or have practiced 2 years in a fully accredited
hospital in a non-training status.
Psychologist: Ph.D., Psy.D. or Ed.D. and 2 years of post-doctoral clinical experience in a recognized
health setting and eligible for the National Register of Health Service Providers in Psychology.
Initial Renown South Meadows Medical Center Medical Staff Status is assigned to be consistent with
Medical Staff Status at Renown Regional Medical Center. Requests for change in Medical Staff Status
at Renown Regional Medical Center will be honored at Renown South Meadows Medical Center. All
mentoring and release from mentoring is monitored at Renown Regional Medical Center with this
information being transmitted to Renown South Meadows Medical Center at the time of advancement to
active status.
All members of the Medical Staff are reappointed every two years in accordance with the Medical Staff
Bylaws, Policies and Procedures and Rules and Regulations. Since reappointment is an affirmation of
good clinical practice, each applicant will provide evidence of activity at a Renown Health System facility
sufficient to demonstrate current clinical competence for the privileges requested.
If the applicant has been granted privileges in Moderate (Conscious) Sedation Analgesia at Renown
Regional Medical Center, those privileges will, upon request, automatically be granted at Renown South
Meadows Medical Center. Documentation of competency to administer Moderate (Conscious)
Sedation Analgesia will be copied and housed in the Practitioner’s File at Renown South Meadows
Medical Center.
Department of Medicine
Revised: 1/2005
I, _____________have met the minimum threshold criteria and am a member in good standing at Renown Regional
Medical Center. I wish to request the following privileges at Renown South Meadows Medical Center:
 Department of Medicine Core Privileges: Which include general medical management of patients to include
assessment; diagnosis; treatment and/or consultative services and discharge. Privileges include the following
procedures: Arterial Puncture; Thoracentesis; Arthrocentesis/Joint Injection; EKG Interpretation; Paracentesis; Skin
Biopsy; Lumbar Puncture and Basic Spirometry.
Please select a sub-specialty(s) if applicable:
 Allergy/Immunology Core Privileges: Which include general medical management of patients presenting with
allergy and immunology disorders including assessment; diagnosis; treatment and/or consultative services and
discharge.
 Dermatology Core Privileges: Which include general medical management of patients presenting with skin
disorders including assessment; diagnosis; treatment and/or consultative services and discharge.
 Endocrinology Core Privileges: Which include general medical management of patients presenting with disorders
of the endocrine system including assessment; diagnosis; treatment and/or consultative services and discharge.
 Hematology/Oncology Core Privileges: Which include general medical management of patients presenting with
disorders of the circulatory system and/or neoplastic disease including assessment; diagnosis; treatment and/or
consultative services and discharge.
 Infectious Disease Core Privileges: Which include general medical management of patients presenting with
infectious disease including assessment; diagnosis; treatment and/or consultative services and discharge.
 Nephrology Core Privileges: Which include general medical management of patients presenting with disorders of
the kidneys including assessment; diagnosis; treatment and/or consultative services and discharge. Included are the
following Hemodialysis; Peritoneal Dialysis; Catheter Insertion; Placement of Temporary Vascular Access for
Hemodialysis; Renal Biopsy and Continuous Arteriovenous and Venovenous Hemodiafiltration.
 Neurology Core Privileges: Which include general medical management of patients presenting with neurological
disorders including assessment; diagnosis; treatment and/or consultative services and discharge.
 Physical Medicine and Rehabilitation Core Privileges: Which include general medical management of patients
requiring rehabilitative services including assessment; diagnosis; treatment and/or consultative services and discharge.
 Pulmonology Core Privileges: Which include general medical management of patients presenting with disorders of
the lungs including assessment; diagnosis; treatment and/or consultative services and discharge.
 Rheumatology Core Privileges: Which include general medical management of patients presenting with
autoimmune and muscular-skeletal disorders including assessment; diagnosis; treatment and/or consultative services
and discharge.
 Radiation Therapy Core Privileges: Which include general management of patients undergoing radiation
therapy and experiencing side effects of that therapy including assessment; diagnosis; treatment and/or
consultative services and discharge.
Department of Medicine
Revised: 1/2005
Special Requests:
(Check each procedure you wish to be granted privileges to perform at Renown South Meadows Medical Center).
Procedure Code
 38.93
 38.91
 38.95
 39.61
 45.24
 89.64


Other Requests
Procedure Requested
Central Venous Catheter Placement
Arterial Catheter Insertion
Renal Dialysis Catheter Placement
CPS Cardiopulmonary Support
Flexible Sigmoidoscopy
Swan-Ganz Catheter Placement
Bronchoscopy
Ventilator Management
Approval Signature
Comments
_______ Moderate (Conscious) Sedation Analgesia
I have been granted privileges in Moderate (Conscious) Sedation Analgesia at Renown Regional Medical Center. Yes
No
_____________________________________
Applicant Signature
________________
Date
The initial appointment or reappointment application, supporting documentation, request for privileges,
education/training, board status, health status and current competency of the above referenced practitioner have
been reviewed. The applicant is a member, in good standing, of the Renown Regional Medical Center Medical
Staff.
I recommend this applicant for Medical Staff Membership.
______________________________________
Medical Director Department of Medicine
_______________
Date
______________________________________
Chief of the Medical Staff
_______________
Date
Date of Recommendation by the Medical Executive Committee: ___________
Date of Approval by the Board of Governors:
Department of Medicine
___________