Download Radiology - San Gorgonio Memorial Hospital

SAN GORGONIO MEMORIAL HOSPITAL
PRIVILEGE DELINEATION LIST
RADIOLOGY
NAME OF APPLICANT:__________________________________ DATE:______________________
YEAR OF BOARD CERTIFICATION/RECERTIFICATION____________
RIVILEGES
CATEGORY
CATEGORY I
QUALIFICATIONS/CRITERIA
CATEGORY 2
MODERATE SEDATION
PRIVILEGES
R
# Done
24 mos
D
P/O
G
DIAGNOSTIC CORE PRIVILEGES
(Procedures considered included in minimal formal training.)
QUALIFICATIONS:
1. Successful completion of an accredited Radiology residency training
program,
AND,
2. Board qualified/certified by the American Board of Radiology with
specific training and recent experience in privileges requested,
OR, (in lieu of Board Certification)
3. Demonstrate comparable competency to perform the privileges
requested based on proctoring reports, reference letters,
activity/operative reports or other documentation acceptable to the
Medical Service, AND have been practicing in Radiology for the past 5
years.
4. Privileges will be proctored per Medicine Service Rules and
Regulations.
DIAGNOSTIC NON-CORE PRIVILEGES
Physicians applying for Diagnostic Non-Core Privileges must have completed a Radiology
Residency and must have exercised these privileges at least two times within the past two
years or provide evidence of Continuing Medical Education.
QUALIFICATIONS:
1. Board qualified/certified by American Board of Radiology,
2. AND, documented evidence of additional training, experience and competence by
hands-on training, special certification, or written documentation of supervised numbers
performed and outcomes.
3. Privileges will be proctored per Medicine Service Rules and Regulations.
IV MEDICATIONS FOR SPECIAL PROCEDURES
(All medications with potential loss of protective reflexes, regardless of route of
administration)
QUALIFICATIONS:
• Documentation of in-house training for non-anesthesiologists in I.V. Sedation
including possible complications, OR,
• Successful completion of didactic and practical examination.
• Training and documentation to be reviewed and approved by Anesthesia Services.
CATEGORY 1 - DIAGNOSTIC CORE PRIVILEGES
Diagnostic Radiology
Bone/Soft tissues – head/neck, chest, abdomen, pelvis, spine, extremities, IVP, fluoroscopies
and barium studies
Mammography
Ultrasound
Head, neck, chest, abdomen, pelvis, extremities, small parts, OB, vascular, breast
Computerized Tomography
Head/neck, chest, abdomen, pelvis, spine, extremities
Magnetic Resonance Imaging (MRI)
Head/neck, chest, abdomen, pelvis, spine, extremities, breast
San Gorgonio Memorial Hospital
Radiology Privilege Delineation
R
# Done
D
P/O
G
24 mos
CATEGORY 1 - DIAGNOSTIC CORE PRIVILEGES
Nuclear Medicine
Thyroid, parathyroid, hematopoietic, reticuloendothelial and lymphatic, GI, musculoskeletal,
cardiovascular, respiratory, CNS and GU.
Drainage Procedures
Percutaneous fluid and abscess drainage-neck, chest, abdomen, pelvis, extremities, breast, small
parts. Galactography and breast localization, lumbar puncture, myelogram, cystogram,
cystourethrogram (retrograde/voiding), nephrostogram, urethrogram, hysterosalpingogram,
sonohystergram, therapeutic steroid/anesthetic injection.
Telemedicine
Interpretation or diagnostic medical images by way of digital transmission and display of
images, which include, but are not limited to, general diagnostic imaging (originating site) from
a distant site (site of reading).
R
# Done
24 mos
D
P/O
G
CATEGORY 2
NON-CORE PRIVILEGES
Echocardiogram
Therapeutic Nuclear Medicine (Thyroid)
Iodine-131 (hyperthyroid therapy only)
Strontium Therapy
Diagnostic Radiology
Biliary and Genitourinary Procedures
Percutaneous transhepatic cholangiogram, percutaneous biliary duct stone removal, dilatation,
stent placements.
Percutaneous nephrostomy, tract dilatation, stent placements.
Stone Extractions-Biliary and Urinary.
Percutaneous Biopsy-Soft tissue and bone, including neck, chest, breast, abdomen, pelvis,
extremities.
Interventional Procedures
IVC filter placement
Venography-extremity, pelvis, IVC and SVC
Thrombolytic therapy-catheter, dialysis graft/fistula
Venous access catheters-placement and removal (short/long term)
Moderate Sedation
Use of Fluoroscopy (certificate required)
Revised/Approved 4/05/2016
Legend: [R] = Requested [# Done 24 mos.] = Procedures done in the last 24 months [D] = Deferred/Denied
[P/O] =Granted with Proctoring/Observation [G] = Granted
San Gorgonio Memorial Hospital
Radiology Privilege Delineation
STAFF CATEGORY REQUESTED:
ACTIVE ( Involved in the care of at least twenty (20) patients per year in this Hospital)
COURTESY (Have not had more than twenty (20) patient contacts within the past twelve (12) months)
CONSULTING (To render clinical services within one’s area of competence and expertise)
TELEMEDICINE Distant Site location in which equipment is located delivering patient care
services – Originating site location where the patient is located. The provider contract with the
entity that serves as the Distant Site.
SIGNATURE OF APPLICANT: _________________________________ DATE ________________
PRINT NAME OF APPLICANT: _______________________________________
APPROVALS:
Applicant may perform privileges and procedures as indicated: [ ]
Exceptions/Limitations:_______________________________________________________________
_____________________________________________________________________________________
I have reviewed the applicant's health status and can attest that there is no health problems that exists
that could affect his or her ability to perform the privileges requested.
____________________________________________________ ________________________________
Medical Services Committee Chairman
Date
____________________________________________________ ________________________________
Credentials Committee Chairman
Date
____________________________________________________ ________________________________
Medical Executive Committee Chairman
Date
____________________________________________________________________________________
Board of Directors Chair
Date
Revised/Approved 4/05/2016
Legend: [R] = Requested [# Done 24 mos.] = Procedures done in the last 24 months [D] = Deferred/Denied
[P/O] =Granted with Proctoring/Observation [G] = Granted