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  1. 1. BANNER ESTRELLA MEDICAL CENTER Delineation of Privileges DERMATOLOGY Physician Name: ______________________________________________________MD/DO Dermatology Core Privileges Requested (Please check if requesting) 28215 Qualifications To be eligible to apply for core privileges in dermatology, the applicant must meet the following qualifications: • Demonstration of an active practice treating dermatologic patients during the past two years or successful completion of a hospital-affiliated formalized residency or clinical fellowship; and • Successful completion of an ACGME- or AOA-accredited residency in dermatology; and • Current certification or active participation in the examination process leading to certification in dermatology by the American Board of Dermatology or the American Osteopathic Board of Dermatology. Board certification must be attained with 5 years of completion of training. _____ 28220 Privileges included in the core Privileges to admit, evaluate, diagnose, provide consultation and treat patients – except where specifically excluded from practice – with illnesses or injuries of the integumentary system (epidermis, dermis, subcutaneous tissue, hair, nails, and cutaneous glands) including consultation and the performance of simple excision and repair, skin and nail biopsy, chemosurgery, topical chemosurgery, cryosurgery, electrosurgery, minor cutaneous surgery including biopsy, patch and photo patch testing except for those special procedures privileges listed below. 28225 Special Procedure Privileges To be eligible to apply for a special procedure privilege listed below, the applicant must demonstrate successful completion of an approved and recognized course or acceptable supervised training in residency, fellowship, or other acceptable experience; and provide documentation of competence in performing that procedure consistent with the criteria set forth in the medical staff policies governing the exercise of specific privileges. Procedure Criteria _____ 21500 Administration of IV conscious sedation See attached criteria. _____ 28230 Use of Laser See attached criteria.
  2. 2. Privileges in Dermatology (cont.) Acknowledgement of Practitioner I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform, and that I wish to exercise at Banner Estrella Medical Center, and; I understand that: (a) In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation. (b) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such a situation my actions are governed by the applicable section of the medical staff bylaws or related documents. Signed: _________________________________________________ Date: ___________________ (Practitioner) Department Chair’s Recommendations: I have reviewed the requested clinical privileges and supportive documentation for the above named applicant and recommend action on the privileges as noted above. _______ Approved _______Approved with Modifications _______Not Approved Comments: ________________________________________________________________________ ________________________________________________________________________ Signed: __________________________________________________ Date: ___________________ (Department Chair) Approved: Department of Medicine: 10/6/04 Medical Executive Committee: 10/18/04 Banner Health Board: 11/18/04
  3. 3. BANNER ESTRELLA MEDICAL CENTER Conscious Sedation Credentialing Criteria MODERATE SEDATION “Conscious Sedation” -A drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patient airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. PRACTITIONERS INTENDING TO INDUCE MODERATE SEDATION ARE COMPETENT TO MANAGE A COMPROMISED AIRWAY AND TO PROVIDE ADEQUATE OXYGENATION AND VENTILATION. Qualifications and Training: 1. Must be a licensed physician (DO or MD) member of the Medical Staff of Banner Estrella Medical Center. AND 2a. Completion of an ACGME/AOA-accredited residency training program in anesthesiology. OR 2b. Provide documentation of current training or education in ATLS or ACLS. Current training or education in PALS or its equivalent is required if treating children. Approved: Medical Executive Committee: 9/27/04 Banner Health Board: 10/20/04
  4. 4. BANNER ESTRELLA MEDICAL CENTER Laser Credentialing Criteria Criteria: Applicants shall provide documentation of: 1. Successful completion of an approved residency program in general surgery, a surgical subspecialty, or other residency program, such as dermatology, where laser technology was used; Or, 2. Participation in at least 10 hours of education and training in laser physics, indications, equipment use, and complications. Such education/training must include hands-on application of the laser. Approved: Medical Executive Committee: 12/7/04 Banner Health Board: 12/16/04