CLINICAL PRIVILEGE REQUEST FOR FAMILY MEDICINE WITH MATERNITY CARE Name: Effective f !m ""#""#"" t!

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INTRODUCTION OF CORE PRIVILEGES

Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity. Core privileges within the department of family medicine should reflect the core curriculum and training offered in accredited family medicine residency programs. The categories and core privileges listed are based on the Program e!uirements for "raduate #edical $ducation in Family #edicine,% a publication by The &ccreditation Council for "raduate #edical $ducation '&C"#$( 'http)**www.acgme.org*ac+ebsite*downloads* C,prog e!*-./pr0/1.pdf(, and the ecommended Curriculum "uidelines for Family #edicine esidents% endorsed by the &merican &cademy of Family Physicians 'http)**www.aafp.org*x-12.3.xml(. esources for family physicians and hospitals for special non4core privileges can be found at the &&FP website at aafp.org, including the &&FP position paper on colonoscopy found at http)**www.aafp.org*online*en*home*policy*policies*c*colonoscopypositionpaper.html.

ELIGI$ILITY

To be eligible to apply for core privileges in family medicine, the applicant must meet the following criteria) Current certification or active participation in the examination process leading to certification in family medicine by the &merican 5oard of Family #edicine or the &merican 6steopathic 5oard of Family Physicians

&nd*or 7uccessful completion of an &ccreditation Council for "raduate #edical $ducation '&C"#$( or &merican 6steopathic &ssociation '&6&( accredited post4graduate training program in family medicine.
FAMILY MEDICINE CORE PRIVILEGES

Re%&e'te( &dmission, evaluation, diagnosis, treatment and management of infants and children, adolescents and adults for most illnesses, disorders and in8uries. Core privileges include but are not limited to) The care of neonates and infants, including both well4baby and ill newborns. Illnesses, disorders and in8uries of childhood, such as pneumonia, asthma, gastrointestinal infections, dehydration and urinary tract infections. Illnesses, disorders and in8uries of adolescence. Illnesses, disorders and in8uries of the adult, including but not limited to conditions of the heart, 9idney, lung, musculos9eletal system, s9in, eye, and nervous system, and including multi4system diseases such as diabetes mellitus, :I;*&I<7 and cancer, and including the care of patients re!uiring admission to intensive care. +omen=s health, including illnesses, disorders and in8uries of the female reproductive and genitourinary systems. Pre4 and post4operative evaluation and care. &cute and chronic diseases of the elderly, including dementias, as well as functional assessment, physiologic and psychologic aspects of senescence and end4of4life care. Psychiatric disorders in children and adults, emotional aspects of non4psychiatric disorders, psychopharmacology, alcoholism and other substance abuse. The care for patients of all ages with acute illnesses, disorders and in8uries in an emergency care setting. Community issues, such as child abuse and neglect, domestic violence, elder abuse and neglect, disease prevention and disaster preparedness. Procedures such as suturing lacerations, removal of non4 penetrating corneal foreign bodies, simple s9in biopsies or excisions, incision and drainage of abscesses, burn care, the management of uncomplicated minor closed fractures and uncomplicated dislocations, and such other procedures that are extensions of the same techni!ues and s9ills.

E)c*&'i!+': Though considered core privileges for Family Medicine, the following privileges will be excluded for this applicant at their request.

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MATERNITY CORE PRIVILEGES

Re%&e'te( &dmit, evaluate and manage pregnancy, labor and delivery, post4partum care, and other procedures related to maternity care, including medical diseases that are complicating factors in pregnancy 'with consultation as appropriate(. &pplicant must provide documentation of at least . months obstetrical rotation during family practice residency with 3/ patients delivered.
SPECIAL NON,CORE PRIVILEGES

To be eligible to apply for special non4core privileges, the applicant must have documented training and*or experience and current competence in performing the re!uested procedure's( consistent with criteria set forth in medical staff policies governing the exercise of specific privileges. This may be accomplished by providing documentation of acceptable supervised training and experience during residency and*or fellowship training, or successful completion of an approved, recogni>ed course when such exists. C,Secti!+ Re%&e'te( Application Criteria: Successful completion of an ACGME or AOA accredited residency training program in family medicine or obstetrics and gynecology. Required Pre ious E!perience: A minimum of "# Cesarean birt$s as primary operator. Ac-+!.*e(/eme+t !f P actiti!+e I ac9nowledge that I have re!uested only those privileges for which by current competence, training and*or experience, I am !ualified to perform and for which I wish to exercise at the :ospital. I understand that I am bound by the applicable bylaws or policies of the :ospital.

Si/+e(: T01e( ! 1 i+te( +ame: De1a tme+t C2ai 3' Rec!mme+(ati!+

Date:

I have reviewed the re!uested clinical privileges and supporting documentation for the above4named applicant and ma9e the following recommendation's() Rec!mme+( a** e%&e'te( 1 ivi*e/e' Rec!mme+( 1 ivi*e/e' .it2 t2e f!**!.i+/ c!+(iti!+'#m!(ificati!+': D! +!t ec!mme+( t2e f!**!.i+/ e%&e'te( 1 ivi*e/e': P ivi*e/e 45 65 75 85 N!te': C!+(iti!+#M!(ificati!+#E)1*a+ati!+

De1a tme+t C2ai Si/+at& e: FAMILY MEDICINE CORE: APPENDI9 A

Date:

CORE PROCEDURES The following are a few examples of procedures from the Family #edicine C6 $, illustrating the depth of Family #edicine training. &s with other specialties, not every applicant for privileges will choose to do all procedures within the core, and may elect to

exclude those procedures from their privilege re!uest. It remains the responsibility of the Family #edicine department chair to forward credentialing*privileging applications to the credentials committee that have been appropriately vetted at the department level. Ge+e a* &rthrocentesis Incision and drainage 'I ? <( abscess Incision and drainage 'I ? <( hemorrhoids 5reast cyst aspiration 5urn care $xcision of s9in and subcutaneous lesions $xcision of cutaneous and subcutaneous tumors and nodules @ocal anesthetic techni!ues @umbar puncture #anagement of uncomplicated closed fractures and dislocations Aeedle biopsies Placement of anterior and posterior nasal hemostatic pac9ing Perform s9in biopsy or excision Peripheral nerve bloc9s Interpretation of electrocardiograms #anagement of non4penetrating corneal foreign body, nasal foreign body epair of lacerations, including those re!uiring layer closure 7uprapubic bladder aspiration $xercise Treadmill testing ;ascular access and intubation of newborns #anagement of abnormal Pap, including colposcopy, cryotherapy and @$$P Insertion and removal of intrauterine devices Tracheal Intubation Circumcision Central venous line placement Paracentesis*Thoracentesis

Mate +it0 Ca e &mniotomy Aormal spontaneous vaginal delivery of a term vertex presentation, including ante4 and postpartum care <ilation and curettage '<?C(, including suction and postpartum $xcision of vulvar lesions at delivery $xternal and internal fetal monitoring &ugmentation of labor

Induction of labor #anagement of uncomplicated labor #anual removal of placenta, post delivery 6perative or assisted vaginal delivery 6xytocin challenge test Post partum hemorrhage 'PP:( Post partum endometritis Pudendal anesthesia epair of episiotomy, including lacerations*extensions epair of vaginal and cervical lacerations <ilation and Curettage for Incomplete &bortion

Aote) &ppendix & is A6T incorporated by reference into the Core document but instead is to be used by an applicant when see9ing privileges when they determine it would be to their benefit. There is no expectation that every physician graduating from a Family #edicine program will have been trained*be competent in all listed procedures. It is the responsibility of the Family #edicine department chair to forward only those re!uests for privileges that have been appropriately reviewed and vetted at the department level. &lternatively, &ppendix & does not represent the entire scope of family medicine. Btili>ing &ppendix & as a mechanism to restrict privileges for family physicians by interpreting the appendix as a comprehensive delineation of services offered by family physicians would be incorrect.