Revised: 10/2004
RENOWN SOUTH MEADOWS MEDICAL CENTER
DEPARTMENT OF SURGERY
Specialty of Neurosurgery
DELINEATION of PRIVILEGES
To be eligible to request initial core clinical privileges, in the Department of Surgery, at RENOWN SOUTH MEADOWS MEDICAL CENTER, an applicant must meet the following minimum threshold criteria:
The Office location of the applicant will be sufficiently close to RENOWN SOUTH MEADOWS MEDICAL CENTER to provide continuity of care to patients as defined by the Medical Staff Policies and Procedures. Additionally, the applicant must retain the same Medical Staff Status at Renown Medical Center as those requested at RENOWN SOUTH MEADOWS MEDICAL CENTER.
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.
Initial RENOWN SOUTH MEADOWS MEDICAL CENTER 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 RENOWN SOUTH MEADOWS MEDICAL CENTER. All mentoring and release from mentoring is monitored at the Renown Health System Affiliated Facility of origin with this information being transmitted to RENOWN SOUTH MEADOWS MEDICAL CENTER 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 Renown Medical Center, those privileges will, upon request, automatically be granted at RENOWN SOUTH MEADOWS MEDICAL CENTER. Documentation of competency to administer Moderate (Conscious) Sedation Analgesia will be copied and housed in the Practitioner’s File at RENOWN SOUTH MEADOWS MEDICAL CENTER.
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 RENOWN SOUTH MEADOWS MEDICAL CENTER:
____ Core Privileges in Neurosurgery (CR.NS)
· Reflecting the position of the American Board of Neurological Surgery, privileges encompass the skills required in the diagnosis and non surgical management of patients of all ages presenting with illnesses, injuries and disorders of the central and peripheral nervous system, including their supporting structures and vascular supply and carpal tunnel procedures.
· Complete care of critically ill patients with underlying neuro-surgical conditions in the Emergency Department and Intensive Care. 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 Renown Medical Center. Yes No
______
Applicant Date
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 Surgery Date
______
Chief of the Medical Staff Date
Date of Recommendation by the Medical Executive Committee: ______
Date of Approval by the Board of Governors: ______
Department of Surgery
Neurosurgery Delineation of Privileges Page 1