New Privilege List - Family Medicine - Sutter Medical Center

SUTTER MEDICAL CENTER, SACRAMENTO
Department of Family Medicine Delineation of Privileges
NAME:
Request Other Special Family Medicine Privileges Appointment Requirements
[ ] EKG Interpretation (privilege allows physician to participate in an EKG
reading panel for official EKG interpretations)
Documentation of training and experience from TJC accredited hospital
or training program of at least 50 EKG interpretations in previous three
years.
[ ] Treadmill Interpretation Documentation of training and experience from a TJC accredited hospital
or training program of at least 10 Treadmill interpretations in previous
three years.
[ ] Post Acute Care Privilege – Continuing care of the patient in the Sutter
Sub- Acute Unit or Sutter Oaks Midtown
[ ] Vasectomy Documentation of training and experience from a TJC accredited hospital
or training program in 12 procedures during previous three years
[ ] Marsupialization or I&D’s of Bartholin Cyst Documentation of training and experience from a TJC accredited hospital
or training program in 2 procedures during previous three years
Proctoring
Required
First (6) cases NONE
First (2) cases NONE
6 cases only if not
requesting admit
privileges
Reappointment
Requirements
NONE
First (2) cases 2 cases
First (1) case 1 case
[ ] Venous Cutdown Documentation of training and experience from a TJC accredited hospital First (1) case 1 case
[ ] Puncture, jugular, external
or training program in 6 procedures during previous three years
First (2) cases 2 cases.
[ ] Lumbar Puncture Documentation of training and experience from a TJC accredited hospital
or training program in 2 procedures during previous three years
First (1) case 1 case
Number
Performed
[ ] Paracentesis Documentation of training and experience from a TJC accredited hospital
or training program in 2 procedures during previous three years
[ ] Thoracentesis Documentation of training and experience from a TJC accredited hospital
or training program in 2 procedures during previous three years
First (1) case; 1 case
First (1) case 2 cases
Please Note: Other special privileges, i.e. Assist in Surgery, Invasive Line Monitoring, Intubation, etc. should be requested through the Medical Staff Department that grants the individual
privilege. Please contact the Medical Staff Services Department (733-3097) if you have questions or need to request privilege lists for other departments.
Acknowledgment of Practitioner: I understand that (a) in exercising clinical privileges granted, I am constrained by Medical Staff Policies and Procedures, Rules and Regulations, and (b) any restriction on the clinical
privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws.
I hereby attest to having performed the stipulated number of procedures as indicated above, thereby meeting the criteria for those privileges I have requested.
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COMMITTEE APPROVALS
Family Medicine QI/Administrative Committee Date:
TEMPORARY PRIVILEGE APPROVAL
Or Dept Chief (in lieu of mtg)
Credentials Committee Date:
Department Chief:
Medical Executive Committee Date:
Board of Directors Date:
Date:
DOCUMENT APPROVALS: Dates:
Family Medicine Administrative Committee November 30, 2010
Credentials Committee January 25, 2011 (outside committee)
Medical Executive Committee January 25, 2011
Medical Policy Committee February 3, 2011
Board of Directors February 17, 2011
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