Clinical Privileges in Allergy/Immunology

Edinburgh/Trafalgar Family Health Centers

CLINICAL PRIVILEGES IN DENTAL MEDICINE

NAME: Effective: to

Status: r Provisional r Active r Associate r Non-Physician Practitioner

r Initial Privileges r Reappraisal r Status Changed to Staff

Qualifications: Current certification or active participation in the examination process leading to certification in dental practice by the American Dental Association, or

Successful graduation from an accredited dental school, or;

Active dental-related practice for at least seven (7) years.

Special Procedures: Successful completion of an approved, recognized course when such exists, or acceptable supervised training in residency, fellowship or other acceptable experience, and documentation of competence to obtain and retain clinical privileges as set forth in medical staff policies governing the exercise of specific privileges.

Observations/Proctoring Requirements: As specified in the medical staff bylaws, credentials policy and procedure manual, or rules and regulations.

Reappointment Requirements: Current demonstrated competence and an adequate volume of current experience with acceptable results in the privileges requested for the past 24 months based on results of quality assessment/improvement activities and outcomes.

Center and Subsidiary Organization Privileges: Privileges granted may be exercised in any of the subsidiary health care facilities of ETFHC, provided such services are offered in the centers.

Note: If any privileges are covered by an exclusive contractual agreement, dentists who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training and experience.

CLINICAL AREA: DENTAL MEDICINE

NAME: Effective: to

Applicant: Place a check mark in the (R) (Requested) column for each privilege requested. New applicants must provide documentation of the number and types of hospital cases during the past 24 months.

For Department Chairperson Use: (A) =Recommend as Requested; (C) =Recommend with Conditions; (N) =Not Recommended. NOTE: If Recommendations for clinical privileges include a condition, modification or are not recommended, the specific condition and reason for same must be stated on the last page of this form.

(R) / (A) / (C) / (N) / DENTAL CORE PRIVILEGES
r / r / r / r / Evaluate, diagnose and provide dental treatment to patients. Privileges include but are not limited to: aleoplasty, amalgam and resin restorations, athletic mouthguards, biopsy, bleaching of vital/non-vital teeth, cast custom posts and cores, cast restorations, ceramic/polymer restorations, dental examination, dental local anestesia, dental radiographs, diagnostic casts, diagnostic tests, simple extraction, gingival flap, gingivectomy/gingivoplasty, hawley retainers, immediate dentures, implant maintenance, incision and drainage, non-surgical root canal therapy, occlusal adjustment,occlusal sealants, occlusal treatment appliances, oral sedation, overdentures, preventive resin restorations, postmortem ID, provisional splint, removable partial dentures, rmovable complete dentures, repair and rebase removable dentures, replantation of avulsed tooth, resin retained fixed partial dentures, scaling and root planing, space maintainers, stabilizatin of subluxated tooth, treatment planning, treament of localized osteitis, treatment of simple traumatic wound, vital pulp therapy. A practitioner, within the scope of his/her field of expertise, is allowed to make a diagnosis based on preliminary interpretation of diagnostic testing and guide treatment.

CLINICAL AREA: DENTAL MEDICINE

NAME: Effective: to

(R) / (A) / (C) / (N) / SPECIAL PROCEDURES (See Qualifications and/or Specific Criteria) (“Per Year” numbers are the suggested minimum number of procedures to be performed to remain competent.)
r / r / r / r /

Active ortho appliances

r / r / r / r / Adult dentition orthodontics
r / r / r / r / Bone replacement graft
r / r / r / r / Closed reduction of jaw dislocation
r / r / r / r / Extraction, complete bony impaction
r / r / r / r / Extraction, complicated
r / r / r / r / Extraction, partial bony impaction
r / r / r / r /

Extraction, soft tissue impaction

r / r / r / r / Free soft tissue graft
r / r / r / r / Guided tissue regeneration
r / r / r / r / Implant restoration(s)
r / r / r / r / Interceptive orthodontics
r / r / r / r / Limited orthodontics
r / r / r / r / Molar uprighing
r / r / r / r / Mucogingival surgery
r / r / r / r / Osteoplasty/ostectomy
r / r / r / r / Subepithelial connective tissue graft
r / r / r / r / Surgical root canal treatment
r / r / r / r / Transitional dentition orthodontics
r / r / r / r / Others:______

CLINICAL AREA: DENTAL MEDICINE

NAME: Effective: to

Acknowledgment of Practitioner

I have requested only those services for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise at ETFHC, and

I understand that:

a. In exercising any clinical privileges granted, I am constrained by ETFHC and Medical Staff policies and rules applicable generally and any applicable to the particular situation.

b. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff ByLaws or related documents.

Signed: Date:

***Department Chairperson’s Recommendations***

Conditions/Modifications:

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and;

r Recommend as Requested r Recommend with conditions r Do Not recommend

Privilege / Condition/Modification
1.
2.
3.

Explanation:

______

Signature, Department Chairperson Date

01/06/06 Page 1 of 4