ob_gyn_dop.pdf

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APPLICATION FOR HOSPITAL PRIVILEGES

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

OBSTETRIC PROCEDURES

Indicate the hospitals for which privileges are being sought:Crouse HospitalSt. Joseph’s Hospital Health CenterUniversity Hospital, SUNY Syracuse

Privileges (please check as applicable) Primary Campus (check one) ___ Upstate University Hospital ___

___ Upstate University Hospital at Community General ___ ___ Upstate Outpatient Surgery Center ___

Name Date

If you are not requesting the same priv ileges at each hospital, please complete a separate delineation form

for each hospital.These privileges are for the applying attending physician only and are not to include other specialists.

In cases where privileges are not recommended, the Chief of Service will indicate what is not recommended andexplain the reasons.

Basic Obstetric Procedures

Successful completion of an approved residency in Obstetrics and Gynecology would permit an applicant

apply for basic privileges. Check the procedures for which priv ileges are being sought . The burden of pro

of qualifications rests wi th the applicant.

Requested Recommend

Vaginal delivery w/ or w/out episiotomyLow forcepsVacuum extractionRepair obstetrical laceration

Abnormal presentationsa. Breech b. multiple gestation Amniocentesis (third trimester)Induction of laborCervical cerclageExternal cephalic versionCircumcisionCesarean deliveryOperative obstetrical procedures,except as listed in next sectionMedical or surgical complications of pregnancy,

except as listed in next sectionSevere hemorrhage of pregnancyProlonged laborSepsis of pregnancyBiophysical profilesManagement of intrauterine fetal demiseFetal scalp sampling



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Name Date

Advanced Obstet ric Procedures Requiring Documented Expertise and Continuing Performance

Fellowship training in Maternal Fetal Medicine and/or documentation of more extensive education and

experience will be required for these additional privi leges. Check the procedures for which privileges are

being sought. The burden of proof of qualifications rests with the applicant.

Requested RecommendComprehensive ultrasound evaluationsChorionic villus biopsy/sampling *, ***Doppler flow evaluation of the fetusFetal umbilical blood sampling *, ***Intrauterine surgery or transfusion *, ***Genetic amniocentesisInsulin dependent diabetesClass III or IV cardiac diseaseManagement of high-risk pregnancy with consultationSevere renal diseaseSevere Intrauterine Growth Restriction

Maternal complications requiring ICU admissionMid forceps delivery

Abdominal cerclageCordocentesis with blood transfusion *, ***In utero bladder shunt placement *, ***In utero pleural shunt placement *, ***Fetal ReductionVesicocentesisOther (please list)

* Not performed at University Hospital at Community General

*** Not performed at St. Joseph’s Hospital Health Center

In requesting the aforementioned privileges, I certify that I have had appropriate experience and/or training indiagnosis, managing, and performing the above.

Signature of Physician: Date

Based upon review of the physician’s training, education, knowledge and current competency, and health status, tclinical privileges, as indicated, are recommended.

Signature, Chairperson/Chief of Department: Date

08/2013



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APPLICATION FOR HOSPTIAL PRIVILEGES

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

GYNECOLOGIC PROCEDURES

ndicate the hospitals for which privileges are being sought:Crouse HospitalSt. Joseph’s Hospital Health CenterUniversity Hospital, SUNY Syracuse

Privileges (please check as applicable) Primary Campus (check one) ___ Upstate University Hospital ___ ___ Upstate University Hospital at Community General ___ ___ Upstate Outpatient Surgery Center ___

Name Date

If you are not requesting the same privi leges at each hospital, please complete a separate delineatio

form for each hospital.These privileges are for the applying attending physician only and are not to include other specialists.

n cases where privileges are not recommended, the Chief of Service will indicate what is not recommended and explain the reasons.

Basic Gynecological Procedures

Successful completion of an approved residency in Obstetrics and Gynecology would permit an applicant to apply for basic

privileges. Check the procedures for wh ich privileges are being sought. The burden of proof of qualifications rests with the

applicant.Requested Recommend Requested Recommend

Vulva Cervix

&D abscess CervicectomyMarsupialization of Bartholin Cyst D&CExcision of Bartholin Cyst Cone Biopsy or LEEP ConizationVulvar Biopsy Excision of cervix stumpVulvectomy, simple Administration of paracervical anesthesia Management of vulvar hematomaManagement of vulvar lacerations Corpus Uteri

Myomectomy, abdominalPerineum and Genitourinary Tract Myomectomy, vaginalPerineoplasty Hysterectomy, abdominalCystostomy/cystotomy repair Hysterectomy, supracervicalCystoscopy Hysterectomy, vaginal

Sigmoidoscopy Uterine suspension

Oviduct

Vagina Ligation of fallopian tubesBiopsy of vaginal mucosa SalpingectomyExcision of cyst/tumor SalpingostomyColpotomy with explorationColpotomy with tubal ligation *** Ovary Colpotomy with drainage of abscessColpocleisis, or LeFort TranspositionPosterior colporrhaphy CystectomyCombined anterior-posterior Oophorectomycolporrhaphy

Combined anterior-posterior Abort ion colporrhaphy with enterocele repair

Colposcopy D&C < 20 weeks ***Colposcopy with biopsy D&C for missed abortionExcision of longitudinal vaginal septumExcision of transverse vaginal septumHymenectomy

Abdominal/Peritoneum/Omentum

Basic Urogynecological Procedures Exploratory LaparotomyWound dehiscence

Anterior colporrhaphy Wound debridementKelly plication of bladder neck AppendectomyMarshall-Marchetti Presacral neurectomyBurch bladder neck suspension Chemotherapy for ectopic pregnancy



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Name Date

Advanced Gynecologic Procedures Requiring Special Expertise

GYNECOLOGIC ONCOLOGY Fellowship training and/or documentation of more extensive education and experience in Gynecologic

Oncology will be required to be eligible for these additional privileges. Check the procedures for which

privileges are being sought. The burden of proof of qualifications rests with the applicant.

Requested RecommendAbdominal wall defect repairAppendectomyBowel ResectionBowel surgeryCentral venous access +Chemotherapy for tumorColostomyColostomy and ileostomy reversalDebulking upper abdomen tumorsExenteration pelvisGastrostomy tube placement

Insertion of cesium or radium applicatorNephrotomyNodes, inguinalNodes, pelvicNodes, periaorticPanniculectomyParacentesis with cytotoxic drugsPeritoneal catheter insertionRadical colpectomyRadical hysterectomyRadical vulvectomyRepair abdominal wall defectSplenectomyStent retrievalTandem and Ovoid brachytherapy placementSupraclavicular node dissectionThoracostomy tubeTrue cut biopsy of pelvis, liver, abdomenTrue cut needle biopsyUrinary diversionUrinary surgery for GYN tumorsVenous access device (Groshong, etc.)

UROGYNECOLOGIC AND PELVIC RECONSTRUCTION PROCEDURES Fellowship training and/or documentation of more extensive education and experience in Urogynecologic

and Pelvic Reconstruction procedures will be required to be eligible for these additional privi leges. Check

the procedures for which privileges are being sought. The burden of proof of qualifications rests with the

applicant. Requested Recommend

Anal sphincteroplastyBotox treatment of urinary urge incontinenceCytoscopy, ureteral CatheterizationExcision of suburethral diverticulumInjection of bulking agentsInterStim Therapy



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Name Date

Advanced Gynecologic Procedures Requiring Special Expertise (Continued)

UROGYNECOLOGIC AND PELVIC RECONSTRUCTION PROCEDURES (Continued)

Requested RecommendNeedle suspension of bladder neck

Paravaginal repairPubovesical slingRepair of recto-vaginal fistulaRepair of vesicovaginal fistulaRetropubic tension free suburethral slingSacrocolpopexySacrospinous ligament fixationTrans obturator suburethral slingVaginal repair with mesh, sacrospinous implant

REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY

Fellowship training and/or documentation of more extensive education and experience in Reproductive

Endocrinology and Infertility wil l be required to be eligible for these additional privil eges. Check theprocedures for which privi leges are being sought. The burden of proof of qualifications rests with the

applicant.Requested Recommend

In vitro fertilization (IVF)Gamete Intrafallopian transfer (GIFT)Microsurgical tubal anastomosisMetroplastyMicrosurgical fimbrioplastyConstruction of neovagina

LASER PROCEDURES in accordance with the accepted policies/guidelines and credentialing criteria as establishby each institution

Please ind icate wh ich hospitals Laser Procedures wil l be util ized __UHCG __CH __SJHHC __UH

Requested Device (laser type) RecommendExternal/Superficial lesions _________________Intraabdominal _________________Laparoscopic _________________Hysteroscopic _________________

LAPAROSCOPIC SURGERY Successful completion of an approved residency in Obstetrics and Gynecology would permit an applicant to applyLaparoscopy Level I privileges. Check the procedures for which privileges are being sought. The burden of proofqualifications rests with the applicant.

Fellowship training and/or documentation of more extensive education and experience will be required to

eligible for Laparoscopy Level II and Laparoscopy Level III. Check the procedures for which privi leges are

being sought. The burden of proof of qualifications rests with the applicant.

Requested Recommend

Laparoscopy: Level IDiagnostic LaparoscopyTubal Sterilization



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Name Date

Advanced Gynecologic Procedures Requir ing Special Expertise (Continued)

Requested RecommendLaparoscopy: Level II

AppendectomyBurch

ColpopexyFulguration of endometriosisLAVHLSH (laparoscopic supracervical hysterectomy)Lysis of adhesionsMyomectomyOophorectomyOvarian cystectomySalpingectomySalpingostomyTotal laparoscopic hysterectomyUtero sacral ablation

Laparoscopy: Level IIIColostomyDissection of pelvic side wallHand assisted debulkingIleostomyLaparoscopic bowel resectionLaparoscopic radical hysterectomyLAVRHOmentectomyParaortic lymph node dissectionPelvic lymphadenectomy

Staging

HYSTEROSCOPIC SURGERY Successful completion of an approved residency in Obstetrics and Gynecology would permit an applicant to applyHysteroscopy Level I privileges. Check the procedures for which privileges are being sought. The burden of prooqualifications rests with the applicant.


eligible Hysteroscopy Level II. Check the procedures for which privileges are being sought . The burden o

proof of qualifications rests wi th the applicant.

Requested RecommendHysteroscopy Level I

DiagnosticHysteroscopy Level II

Excision of polypsExcision of submucous myomaExcision of septum



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Name Date


Requested RecommendHysteroscopy Level II (Continued)

Endometrial ablationa. Laser b. Electrosurgicalc. Thermal balloon

d. Radiofrequency (NovaSure)e. Cryoablationf. Hydrothermal ablation

Tubal obstructive or ablative proceduresfor sterilization (Essure) ***

Adiana tubal sterilization ***MyosureTubal catheterization

ROBOTIC SURGERY


eligible for Robotic Surgery. Check the procedures for which privileges are being sought. The burden ofproof of qualifications rests with the applicant. At St. Joseph's Hospital Health Center the physician must

have Active privileges to apply for Robotic Surgery.Requested Recommend

AppendectomyBladder repairBowel repairOmentectomyPelvic massPelvic periaortic lymphadenectomy and stagingRadical hysterectomy, lymphadenectomy with or without BSO

Sacral colpopexyTotal hysterectomy, BSO, lymphadenectomyTubal anastomosis

Other advanced procedures not listed above (please list):_______________________________________________________________________________________________________________________________________

* Not performed at Community-General Hospital** Not performed at Crouse Hospital

*** Not performed at St. Joseph’s Hospital Health Center**** See attachment+ Requires CVP education and training for all University Hospital facilities

Moderate SedationModerate Sedation (Conscious Sedation) privileges in accordance with the accepted policies/guidelinesand credentialing criteria for the utilization of Moderate Sedation

If Moderate Sedation is requested, please indicate the number of times performed within last two years ________

Please indicate which hospitals Moderate Sedation will be utilized __UHCG __CH __SJHHC __UH



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Name Date


Requested Recommend

Acupuncture (special certification required)

Acupuncture for gynecologyAcupuncture for obstetrics

Fluoroscopy / C-arm Radiation Use (special credentialing required)

Age Restr ic tion

I do not treat patients (ci rcle one) under/over the age of ____ years.

No restrictions ___

In requesting the aforementioned privileges, I certify that I have had appropriate experience and/or training indiagnosis, managing, and performing the above.

Signature of Physician: Date

Based upon review of the physician’s training, education, knowledge and current competency, and health status, tclinical privileges, as indicated, are recommended.

Signature, Chairperson/Chief of Department: Date

06/2014

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