Pinnaclehealth Hospital

PinnacleHealth Hospital

REQUEST FOR EXPRESS

Basic Education and Minimum Formal Training

QUALIFICATIONS FOR EXPRESS MEDICINE PRIVILEGS: Current Board Certification or actively pursuing Board Certification

within five (5) years of Medical Staff membership in one of the following: Pediatrics and Internal Medicine, Family Medicine or Emergency Medicine. Successful completion of an accredited ACGME or AOAGME approved residency program.

Current ACLS Certification required if not Board Certified in Emergency Medicine.

Request General Express Medicine Core Privileges Approve Disapprove

Assess, evaluate, diagnose and provide initial treatment and consultation to patients of all age groups except as specifically excluded from practice who present with any minor illnesses or injuries or general medical problems.
Privileges include: Interpretation of plain radiology, EKG’s and rhythm strips, management of acute injuries and lacerations, initial fracture care, splinting, joint aspirations and joint reductions, I&D of simple and moderate abscess, Epistaxis care, remove superficially imbedded foreign bodies in skin or body orifices, slit lamp and eye care procedures
Prescribe and dispense drugs relevant to the area of practice of the provider
Prescribe and dispense Schedule II controlled substances
Prescribe and dispense Schedule III, IV and/or V controlled substances

Please list any Core Privileges you do not wish to exercise:

______

I have requested and will perform only those privileges for which I am qualified by education, training, current experience and demonstrated performance. I further acknowledge that my professional liability insurance coverage includes all of the privileges which I am seeking and I will, at all times, maintain coverage for all privileges performed. I further acknowledge that professional liability insurance coverage limits must be in those amounts required by Pennsylvania law or as otherwise required by the Medical Staff.

I understand that in exercising clinical privileges, I am subject to the bylaws, policies, procedures, rules and regulations of the Medical Staff.

______

Practitioner’s Signature Date

Based upon the review of training, education, knowledge, current competency and health status, I recommend the indicated privileges.

______

Department Chair Date

Date recommended by Credentialing Committee: ______

Date recommended by Medical Executive Committee: ______

Date approved by Board of Directors: ______