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  • Ambulatory Obstetrics Gynecology

    Transféré par

    Nelson R. Pou
    149 vues4 pages
    The document is a privilege request form for an applicant seeking office-based gynecology and obstetrics privileges at Mercy Hospital Cadillac. It lists the applicant's basic education and training requirements to include an MD or DO degree and successful completion of an approved residency in obstetrics and/or gynecology. It then lists the specific office-based gynecology and obstetrics procedures and treatments the applicant is requesting privileges for, including procedures like endometrial biopsies, IUD insertions, and office-based hysteroscopy. Special requests for procedures like gynecological lasers and endometrial ablation that require additional training are also noted. The form is to be signed by the

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    The document is a privilege request form for an applicant seeking office-based gynecology and obstetrics privileges at Mercy Hospital Cadillac. It lists the applicant's basic education and training requirements to include an MD or DO degree and successful completion of an approved residency in obstetrics and/or gynecology. It then lists the specific office-based gynecology and obstetrics procedures and treatments the applicant is requesting privileges for, including procedures like endometrial biopsies, IUD insertions, and office-based hysteroscopy. Special requests for procedures like gynecological lasers and endometrial ablation that require additional training are also noted. The form is to be signed by the

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    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    149 vues4 pages

    Ambulatory Obstetrics Gynecology

    Transféré par

    Nelson R. Pou
    The document is a privilege request form for an applicant seeking office-based gynecology and obstetrics privileges at Mercy Hospital Cadillac. It lists the applicant's basic education and training requirements to include an MD or DO degree and successful completion of an approved residency in obstetrics and/or gynecology. It then lists the specific office-based gynecology and obstetrics procedures and treatments the applicant is requesting privileges for, including procedures like endometrial biopsies, IUD insertions, and office-based hysteroscopy. Special requests for procedures like gynecological lasers and endometrial ablation that require additional training are also noted. The form is to be signed by the

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 4

    MERCY HOSPITAL CADILLAC PRIVILEGE REQUEST FORM OFFICE BASED PRIVILEGES NAME_______________________________ DATE_____________________________

    Employed Providers within Mercy Hospital Cadillac owned practices whose practice include outpatient care are required to complete the Delineation of Ambulatory Privileges. Basic Education: MD or DO

    Minimum formal training: The applicant must demonstrate successful completion of an approved residency training program in Obstetrics and/or Gynecology. ***************************************************************************** ** OFFICE BASED GYNECOLOGY REQUESTED

    Privileges to evaluate, diagnose, consult and provide care necessary to correct or treat female patients of all ages presenting with illnesses, injuries, an d disorders of the gynecological or genitourinary system and non-surgical treatment of illnesses and injuries of the mammary glands. Also including: Incision and Drainage Destruction of Vulva Lesions Destruction of Vaginal Lesions Simple/Complex Endometrial Biopsy Endocervical Curettage Cervical Biopsy Colposcopy Ablative cervical procedure IUD Insertion /Removal Hymen Removal/Excision Hysterosalpingography Subdermal implants insertion and removal Skin biopsies Fine Needle aspiration biopsies Office based hysteroscopy Special Requests: If you wish to request any of the following privileges, please indicate by placing an x next to the privilege desired. A separate privilege form will be forwarded to you for each special request. Requested Procedure Minimum formal training:
    # that must be performed each credentialing period to maintain privileges

    Gynecological laser If the procedure is covered in the residency surgery training program, the applicant must provide

    Endometrial ablation

    evidence that the program included hands-on application of the laser. If covered in a residency/post-graduate education course, documentation of completion of the course is required. If the procedure is covered in the residency training program, the applicant must provide evidence that the program. If the procedure is not covered in the residency training program, the applicant must participate in a residency/postgraduate education course in endometrial ablation, which includes hands-on training, or undergo proctoring for an agreed-upon number of cases. REQUESTED

    OFFICE BASED OBSTETRICS

    Privileges to evaluate, diagnose, treat and provide consultation to female patients presenting in any condition or stage of pregnancy, including injuries and disorders of the reproductive system.

    __________________________________________ Applicants signature

    ___________________________ Date

    MERCY HOSPITAL CADILLAC Name Date DELINEATION OF PRIVILEGES REQUESTED OBSTETRICS & GYNECOLOGY [ ] PRIVILEGES RECOMMENDED AS REQUESTED COMMENTS: [ ] RECOMMENDED NOT

    _____________________________ __ Obstetric / Gynecology Section Chief Date ************************************************************************* [ ] PRIVILEGES RECOMMENDED AS REQUESTED COMMENTS: [ ] RECOMMENDED NOT

    _____________________________ __ Surgical Services Department Chair Date ************************************************************************* [ ] PRIVILEGES RECOMMENDED AS REQUESTED COMMENTS: [ ] RECOMMENDED NOT

    Credentialing Officer

    _____________________________ __ Date

    ************************************************************************* SUBSEQUENT ACTIONS WERE TAKEN BY: MEDICAL EXECUTIVE COMMITTEE:Recommended: Yes [ ] No [ ]

    Date_______________________________ Approved: MERCY BOARD Yes [ ] No [ ]

    Date________________________________

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