r Harford Memorial Hospital r Upper Chesapeake Medical Center

CLINICAL PRIVILEGES IN INTERNAL MEDICINE

Name:______Page 1 of 3

Qualifications: Successful completion of an accredited ACGME or AOA residency program in internal medicine, and

Current certification or active participation in the examination process leading to certification in general internal medicine by the American Board of Internal Medicine or the American Osteopathic Board of Internal Medicine with certification to be achieved within two (2) examination cycles after completion of the educational and clinical requirements. If certification is not attained within this time period, privileges will be denied or revoked.

Required Previous Experience: Applicant must provide documentation of provision of inpatient services to at least 30 patients in the last 12 months. Recent completion of residency training fulfills this requirement. In the event there is a lapse in clinical practice, the Medical Executive Committee shall determine the competency requirement.

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, Credentialing Policy, 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.


CLINICAL AREA: INTERNAL MEDICINE Page 2 of 3

Name:______

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

(R)=Requested (A)=Recommended AS Requested (C)=Recommended 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) INTERNAL MEDICINE CORE PRIVILEGES

r r r r Admit, evaluate, diagnose, and non-surgically treat including consultation for patients above the age of 16 admitted or in need of care to treat general medical problems. Privileges include, but not limited to, EKG interpretation (initial pending final interpretation).

(R) (A) (C) (N) SPECIAL PROCEDURES

(See Qualifications and/or Specific Criteria)

r r r r Lumbar puncture

Prerequisite: Formal training and evidence of five (5) procedures during the past two years.

r r r r Thoracentesis

Prerequisite: Formal training and evidence of five (5) procedures during the past two years

r r r r Paracentesis

Prerequisite: Formal training and evidence of five(5) procedures during the past two years

r r r r Diagnostic flexible sigmoidoscopy without biopsy

Prerequisite: Formal training and evidence of five(5) procedures during the past two years

r r r r Ventilator management

Prerequisite: Formal training and evidence of twenty (20) procedures during the past two years

r r r r Insertion and management of central venous catheter

Prerequisite: Formal training and evidence of five (5) procedures during the past two years

r r r r Insertion and management of pulmonary artery catheter

Prerequisite: Formal training and evidence of twenty (20) procedures during the past two years

r r r r Insertion of peripheral arterial line

Prerequisite: Formal training and evidence of ten (10) procedures during the past two years

r r r r Acupuncture

r r r r Administration of moderate sedation

CLINICAL AREA: INTERNAL MEDICINE Page 3 of 3

Name:

Acknowledgment of Practitioner

I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise at UPPER CHESAPEAKE HEALTH, and;

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) 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/Division Chair’s Recommendation***

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

Privileges / Condition/Modification
1
2
3
Explanation:

______

Department/Division Chair - Signature Date

______

Department/Division Chair - Signature Date

07/10/01