Cooper University Hospital

Department of Physical & Rehabilitation Medicine

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COOPER UNIVERSITY HOSPITAL

DEPARTMENT OF Physical & Rehabilitation Medicine

DELINEATION OF PRIVILEGES

NAME: ______

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Physical & Rehabilitation Medicine Core Privileges

Qualifications:

To be eligible to apply for core privileges in Physical & Rehabilitation Medicine, the applicant must meet the following qualifications:

·  Demonstration of the provision of inpatient or consultative services for at least 50 physical and rehabilitative medicine patients during the past 24 months. This can include acute care hospitals, rehabilitation hospitals, and nursing facilities. (Residency satisfies this requirement).

AND

·  Successful completion of an ACGME-or AOA-accredited residency in Physical & Rehabilitation Medicine.

·  Current certification or active participation in the examination process leading to certification in physical & rehabilitation medicine by the American Board of Physical Medicine and Rehabilitation or the American Osteopathic Board of Rehabilitation Medicine as required by the Medical Staff Bylaws.

·  Core Privileges Include: Privileges to admit, evaluate, diagnose, and provide nonsurgical therapeutic treatments to inpatients and outpatients of all ages – except as specifically excluded from practice and except for those special procedure privileges listed below – with neuromuscular or musculoskeletal disorders, including the provision of consultations.

Privileges include physical examination of pain/weakness/numbness syndromes (both neuromuscular and musculoskeletal) with a diagnostic plan and/or prescription for treatment that may include the use of physical agents and/or other interventions; evaluation, prescription, and supervision of medical and comprehensive rehabilitation goals and treatment plans. This includes ordering Physical, Occupational, and Speech Therapy, Prosthetics, Orthotics and Shoes, Ambulatory Aids, Home Equipment. Core privileges also include peripheral joint injections, trigger point injections, and peripheral nerve injections, but does not include spinal injections (see Special privileges).

 Requested /  Recommended /  Not Recommended
 Recommended with the following modification(s) and reason(s).

Special Privileges (See Qualifications and/or specific criteria):

To be eligible to apply for a special procedure privilege listed below, the applicant must demonstrate successful completion of an approved and recognized course or acceptable supervised training in residency, fellowship, or other acceptable experience; and provide documentation of competence in performing that procedure consistent with the criteria set forth in the medical staff policies governing the exercise of specific privileges.

Privilege / Criteria / Requested / Recommended / Not Recommended
Spinal Injections / Fellowship training or other acceptable equivalent training
Electromyographic Examination / Successful completion of 150 EMG/NCV studies during an accredited PM&R residency documented in a letter of reference form the residency program director.
OR
Performance of 25 studies under the direct supervision of the Department Chief, or his designee.
Acupuncture / Must meet established hospital-wide criteria

Reappointment:

·  Reappointment should be based on unbiased, objective results of care according to the organization’s existing quality assurance mechanism

·  Applicants must demonstrate their maintained competence with evident that they provided PM&R inpatient and/or consultative services for at least 50 patients over the past 24 months.

·  50 CME hours per year are required

Acknowledgement of Practitioner:

I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform, and that I wish to exercise at The Cooper Health System.

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 a situation my actions are governed by the applicable section of the medical staff bylaws or related documents.

Signed:______Date:______

Department Chief’s Recommendations:

I have reviewed the requested clinical privileges and supportive documentation for the above named applicant and recommend action on the privileges as noted above.

Signed:______Date:______

Approved Board of Trustees: 8-3-04