Download Rheumatology Privilege Form 06-14

Grinnell Regional Medical Center
Department of Medicine
Clinical Privilege Request Form
Practice Area: Rheumatology
 Initial Appointment
 Change in Privileges
Applicant:
Staff Category:
 Renewal of Privileges
Applicant: Place a check in the (R) box for privileges Requested.
Note: Please strike through and initial those privileges in the basic privilege set that you are not requesting.
Recommending individual/committee must note: (A) = recommend approval as requested, (C) = recommended
w/conditions/modifications or (N) = not recommended. NOTE: If conditions or modifications are noted, the specific
condition and reason for same must be stated on the last page.
Requested
Privilege
(R)

Committee Action
Rheumatology Basic Privileges
Evaluate, diagnose, treat, and provide consultation to adult patients with
diseases of the joints, muscles, bones, and tendons including rheumatoid
arthritis, infections of joint and soft tissue; osteoarthritis; metabolic diseases of
the bone; systemic lupus erythematosus; scleroderma/systemic sclerosis and
crystal-induced synovitis; polymyositis; spondyloarthropathies; vasculitis;
regional, acute, and chronic musculoskeletal pain syndromes; nonarticular
rheumatic disease, including fibromyalgia; nonsurgical exercise-related injury;
systematic disease with rheumatic manifestations; osteoporosis; and Sjogren’s
Syndrome. Basic privileges include the procedures listed and such other
procedures that are extensions of the same techniques and skills:




(A)

(C)

(N)

Perform history and physical exam
Diagnostic aspiration and analysis by light and compensated polarized light microscopy of synovial
fluid
Therapeutic injection of diarthrodial joints, bursae, tenosynovial structures, and entheses
Use of nonsteroidal anti-inflammatory medications, disease-modifying medications, biological
response modifiers, glucocorticoids, cytotoxic medications, antihyperuricemic medications, and
antibiotic therapy for septic joints
Additional Privileges
A request for any additional privileges not included on this form must be submitted in writing to the Medical
Staff Affairs Office and will be forwarded to the appropriate review committee to determine the need for
development of specific criteria, personnel, and equipment requirements.
Emergency
In the case of an emergency, any member of the medical staff, to the degree permitted by his or her license
and regardless of medical staff status or clinical privileges, shall be permitted to do everything reasonably
possible to save the life of a patient or to save a patient from serious harm.
Acknowledgement of Practitioner
I have requested only those privileges which by education, training, current experience and demonstrated
performance I am qualified to perform and which I wish to exercise at Grinnell Regional 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. I have read and agree to abide by the medical staff bylaws, rules and regulations, and department of
surgery rules and regulations.
Applicant’s Signature as it will appear in the Medical Record
Initials
Date
Rheumatology
Page 1 of 2
Developed: 06-14
Grinnell Regional Medical Center
Department of Medicine
Clinical Privilege Request Form
Applicant:
Section Chief Review
I certify that I have reviewed and evaluated this individual’s request for clinical privileges, the verified
credentials, quality data and/or other supporting information. Based on the information available and/or
personal knowledge, I recommend the practitioner be granted:
 Privileges as requested
 Privileges with modifications (see description of modifications)
 Do not recommend
Privilege
Condition/Modification/Explanation
Section Chief Signature
Date
Department Chair Review
I certify that I have reviewed and evaluated this individual’s request for clinical privileges, the verified
credentials, quality data and/or other supporting information. Based on the information available and/or
personal knowledge, I recommend the practitioner be granted:
 Privileges as requested
 Privileges with modifications (see above)
 Do not recommend
Department Chair Signature
Date
Medical Staff Executive Committee_______________________ (Date of Committee Review/Recommendation)
 Privileges as requested
 Privileges with modifications (see above)
 Do not recommend
Board of Directors____________________________(Date of Board Review/Action)
 Privileges as requested
 Privileges with modifications (see above)
 Do not recommend
Rheumatology
Page 2 of 2
Developed: 06-14