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Physician Credentialing Privilege List

PROCESS

Code

1) Perform Unsupervised         3) Annual Medical Peer Review Satisfactory     5) Not Requested

2) Perform with Supervision    4) Facility Unable to Support                               6) Not Approved

Name of Physician:

Name of Medical Facility:

 

Privilege LIST

Annual Peer Review

Requested

Approved

A.

Provide Hyperbaric Management

     

1

Decompression Illness

     

2

Carbon Monoxide Poisoning/Smoke Inhalation

     

3

Gas Embolism

     

4

Gas Gangrene

     

5

Necrotizing Soft Tissue Infections

     

6

Crush Injury/Compartment Syndrome/
Traumatic Ischemias

     

7

Radiation Tissue Damage

     

8

Compromised Grafts and Flaps

     

9

Problem/Compromised Wounds

     

10

Osteomyelitis

     

11

Thermal Burns

     

12

Brain Abscess

     

13

Other UHMS Accepted Indications

     

14

Hyperbaric Medicine Complications
(Barotrauma, Oxygen Toxicity, etc.)

     

15

Apply Standard Treatment Schedules
and Modify when Clinically Indicated.

     

B.

Primary Procedures

     

1

Minor Surgical Debridement of Wounds

     

2

Transcutaneous Oximetry Interpretation

     

3

Complicated Wound management

     

4

Local and Regional Anesthesia

     

5

Wound Biopsy

     

6

Emergency Myringotomy

     

7

Endotracheal Intubation

     

8

Simple Laceration Repair

     

9

Emergency Chest Tube Placement

     

C.

Other Procedures

     

1

Major Surgical Debridement of Wounds

     

2

Pinch Grafts

     

3

Split Thickness Skin Grafts

     

4

Elective PE Tube Placement

     

5

Central Line Placement

     

D.

All Safety and Compliance from Previous
12 months Completed

YES

NO

RECOMMENDATION

  Recommend Approval

  Recommend Approval with Modifications (specify)

  Recommend Disapproval (specify)

The approved privileges will expire on: ______________________

Signature of Medical Director ______________________________________ Date: _________

Signature of Safety Director _______________________________________  Date: _________

Policy Effective Date:

Reviewed Date:

Revised Date:

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