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1 APPLICATION FOR HOSPITAL PRIVILEGES DEPARTMENT OF OBSTETRICS AND GYNECOLOGY OBSTETRIC PROCEDURES Indicate the hospitals for which privileges are being sought: Crouse Hospital St. J oseph’s Hospital Health Center University 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 ___
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   1  APPLICATION FOR HOSPITAL PRIVILEGES DEPARTMENT OF OBSTETRICS AND GYNECOLOGY OBSTETRIC PROCEDURES Indicate the hospitals for which privileges are being sought: Crouse Hospital St. Joseph’s Hospital Health Center University 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 privileges 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 and explain the reasons.  Basic Obstetric Procedures Successful completion of an approved residency in Obstetrics and Gynecology would permit an applicant to apply for basic privileges. Check the procedures for which privileges are being sought. The burden of proof of qualifications rests with the applicant. Requested Recommend Vaginal delivery w/ or w/out episiotomy Low forceps Vacuum extraction Repair obstetrical laceration  Abnormal presentations a.  Breech  b.  multiple gestation  Amniocentesis (third trimester) Induction of labor Cervical cerclage External cephalic version Circumcision Cesarean delivery Operative obstetrical procedures, except as listed in next section Medical or surgical complications of pregnancy, except as listed in next section Severe hemorrhage of pregnancy Prolonged labor Sepsis of pregnancy Biophysical profiles Management of intrauterine fetal demise Fetal scalp sampling   2  Name Date  Advanced Obstetric 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 privileges. Check the procedures for which privileges are being sought. The burden of proof of qualifications rests with the applicant. Requested Recommend Comprehensive ultrasound evaluations Chorionic villus biopsy/sampling *, *** Doppler flow evaluation of the fetus Fetal umbilical blood sampling *, *** Intrauterine surgery or transfusion *, *** Genetic amniocentesis Insulin dependent diabetes Class III or IV cardiac disease Management of high-risk pregnancy with consultation Severe renal disease Severe Intrauterine Growth Restriction Maternal complications requiring ICU admission Mid forceps delivery  Abdominal cerclage Cordocentesis with blood transfusion *, *** In utero bladder shunt placement *, *** In utero pleural shunt placement *, *** Fetal Reduction Vesicocentesis Other (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 in diagnosis, 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, the clinical privileges, as indicated, are recommended. Signature, Chairperson/Chief of Department: Date 08/2013   3  APPLICATION FOR HOSPTIAL PRIVILEGES DEPARTMENT OF OBSTETRICS AND GYNECOLOGY GYNECOLOGIC PROCEDURES Indicate the hospitals for which privileges are being sought: Crouse Hospital St. Joseph’s Hospital Health Center University 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 privileges 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 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 which privileges are being sought. The burden of proof of qualifications rests with the applicant. Requested Recommend Requested Recommend Vulva Cervix  I&D abscess Cervicectomy Marsupialization of Bartholin Cyst D&C Excision of Bartholin Cyst Cone Biopsy or LEEP Conization Vulvar Biopsy Excision of cervix stump Vulvectomy, simple  Administration of paracervical anesthesia  Management of vulvar hematoma Management of vulvar lacerations Corpus Uteri  Myomectomy, abdominal Perineum and Genitourinary Tract Myomectomy, vaginal Perineoplasty Hysterectomy, abdominal Cystostomy/cystotomy repair Hysterectomy, supracervical Cystoscopy Hysterectomy, vaginal Sigmoidoscopy Uterine suspension Oviduct   Vagina Ligation of fallopian tubes Biopsy of vaginal mucosa Salpingectomy Excision of cyst/tumor Salpingostomy Colpotomy with exploration Colpotomy with tubal ligation *** Ovary  Colpotomy with drainage of abscess Colpocleisis, or LeFort Transposition Posterior colporrhaphy Cystectomy Combined anterior-posterior Oophorectomy colporrhaphy Combined anterior-posterior  Abortion  colporrhaphy with enterocele repair Colposcopy D&C < 20 weeks *** Colposcopy with biopsy D&C for missed abortion Excision of longitudinal vaginal septum Excision of transverse vaginal septum Hymenectomy  Abdominal/Peritoneum/Omentum Basic Urogynecological Procedures Exploratory Laparotomy Wound dehiscence  Anterior colporrhaphy Wound debridement Kelly plication of bladder neck Appendectomy Marshall-Marchetti Presacral neurectomy Burch bladder neck suspension Chemotherapy for ectopic pregnancy   4   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 Recommend  Abdominal wall defect repair  Appendectomy Bowel Resection Bowel surgery Central venous access + Chemotherapy for tumor Colostomy Colostomy and ileostomy reversal Debulking upper abdomen tumors Exenteration pelvis Gastrostomy tube placement Insertion of cesium or radium applicator Nephrotomy Nodes, inguinal Nodes, pelvic Nodes, periaortic Panniculectomy Paracentesis with cytotoxic drugs Peritoneal catheter insertion Radical colpectomy Radical hysterectomy Radical vulvectomy Repair abdominal wall defect Splenectomy Stent retrieval Tandem and Ovoid brachytherapy placement Supraclavicular node dissection Thoracostomy tube True cut biopsy of pelvis, liver, abdomen True cut needle biopsy Urinary diversion Urinary surgery for GYN tumors Venous 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 privileges. Check the procedures for which privileges are being sought. The burden of proof of qualifications rests with the applicant.  Requested Recommend  Anal sphincteroplasty Botox treatment of urinary urge incontinence Cytoscopy, ureteral Catheterization Excision of suburethral diverticulum Injection of bulking agents InterStim Therapy
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