Revised: 10/2004

Renown South Meadows Medical Center

DEPARTMENT OF SURGERY

Plastic Surgery

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 Regional 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 Renown Regional Medical Center. Requests for change in Medical Staff Status at Renown Regional Medical Center will be honored at Renown South Meadows Medical Center. All mentoring and release from mentoring is monitored at Renown Regional Medical Center 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 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 Regional 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 Renown Regional Medical Center. I wish to request the following privileges at Renown South Meadows Medical Center:

____ Core Privileges in Plastic Surgery

Reflecting the position of various specialty boards and the practice at Renown South Meadows Medical Center, privileges encompass the skills required in the diagnosis, preoperative, operative and postoperative management of patients of all ages in the following areas:

·  Congenital defects of the head and neck

·  Head and neck neoplasms

·  Breast

·  Hand and upper extremity

·  Trunk and genitalia

·  Lower extremities

·  Skin and soft tissue neoplasms

·  Burns

·  Cosmetic repairs

·  Harvesting free flap

·  Liposuction

·  Complex hand surgery and Microsurgery.

______CO2 Laser (LS.CO)

I have documentation that a certified course has been taken; or certificate or verification of training during residency has been provided to Renown Regional Medical Center and the first two cases were proctored.

Yes No

______Moderate (Conscious) Sedation Analgesia

I have been granted privileges in Moderate (Conscious) Sedation Analgesia at Renown Regional Medical Center. Yes No

______

Applicant Signature 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 the Renown Regional Medical Center Medical Staff.

I recommend this applicant for Medical Staff Membership.

______

Chief 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

Plastic Surgery Delineation of Privileges Page 1 of 3