DEPARTMENT OF SURGERY
General and Vascular Surgery
DELINEATION of PRIVILEGES
To be eligible to request initial core clinical privileges, in the Department of Surgery, at RenownRehabilitationHospital, an applicant must meet the following minimum threshold criteria:
The Office location of the applicant will be sufficiently close to RenownRehabilitationHospital to provide continuity of care to patients as defined by the Medical Staff Policies and Procedures. Additionally, the applicant must maintain privileges at a second hospital providing emergency services that is directly or indirectly affiliated with Renown Health System.
The applicant must have actively practiced 18 of the last 24 months. The applicant must have actively practiced in an accredited hospital 2 of the last 5 years.
Medical Doctor and Doctor of Osteopathic Medicine Qualification: Satisfactorily completed an ACGME approved postgraduate residency training program or have practiced 2 years in a fully accredited hospital in a non-training status.
Doctor of Dental Surgery Qualification: Graduate of a school accredited by the Council of Dental Education by the American Dental Association.
Podiatry Qualification: Successful completion of a one-year residency, approved by the Council on Podiatric Medical Education.
InitialRenownRehabilitationHospital Medical Staff Status is assigned to be consistent with Medical Staff Status at the Renown Health System Affiliated Facility of origin. Requests for change in Medical Staff Status at the Renown Health System Affiliated Facility will be honored at RenownRehabilitationHospital. All mentoring and release from mentoring is monitored at the Renown Health System Affiliated Facility of origin with this information being transmitted to RenownRehabilitationHospital at the time of advancement to active status.
All members of the Medical Staff are reappointed every two years in accordance with the Medical Staff Bylaws, Policies and Procedures and Rules and Regulations. Since reappointment is an affirmation of good clinical practice, each applicant will provide evidence of activity at a Renown Health System Affiliated Facility sufficient to demonstrate current clinical competence for the privileges requested.
If the applicant has been granted privileges in Moderate (Conscious) Sedation Analgesia at RenownRegionalMedicalCenter, those privileges will, upon request, automatically be granted at RenownRehabilitationHospital. Documentation of competency to administer Moderate (Conscious) Sedation Analgesia will be copied and housed in the Practitioner’s File at RenownRehabilitationHospital.
I, ______have met the minimum threshold criteria and am a member in good standing at a Renown Health System Affiliated Facility. I wish to request the following privileges at RenownRehabilitationHospital:
______Core Privileges in General and Vascular Surgery (CR.SU)
- Reflecting the position of the American Board of Surgery, General and Vascular Surgical privileges encompass the skills required in the diagnosis, preoperative and postoperative management in the following areas of the body:
- alimentary tract
- abdomen and its contents
- breasts, skin, and soft tissue
- head and neck including congenital, endocrine and oncologic disorders particularly tumors of the skin, thyroid and parathyroid gland
- endocrine system
- Complete care of critically ill patients with underlying surgical conditions. This includes placement of monitoring devices such as Swan-Ganz catheters and arterials lines and ventilator management.
______Moderate (Conscious) Sedation Analgesia
I have been granted privileges in Moderate (Conscious) Sedation Analgesia at RenownMedicalCenter. Yes No
Applicant’s Printed NameApplicant’s Initials as used in Medical Records
The initial appointment or reappointment application, supporting documentation, request for privileges, education/training, board status, health status and current competency of the above referenced practitioner have been reviewed. The applicant is a member, in good standing, of a Renown Health System Affiliate Medical Staff.
I recommend this applicant for Medical Staff Membership.
Medical Director Department of SurgeryDate
Chief of the Medical StaffDate
Date of Recommendation by the Medical Executive Committee:______
Date of Approval by the Board of Governors: ______
Department of Surgery
Section of Medical Rehabilitation Staff
General and Vascular Surgery Delineation of Privileges Page 1 of 2