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Home , Gynecologic oncology

1/3/2018 www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443

Department of OB/GYN & Reproductive Sciences CAT 1 Basic Privileges: Patient management, including H & Ps and diagnostic and therapeutic treatments, procedures and interventions encompassing the areas described below and similar activities. Requiring a level of training generally associated with persons who have completed the program prescribed by the American Board of and Gynecology, and a level of skill and ability generally associated with persons who are diplomates of that board. A Care of women before, during and after pregnancy including administration of topical and local . B Treatment of diseases and disorders of the reproductive tract in women, including administration of topical and local anesthesia. A Laparoscopy CAT 2 Privileges: Patient management at this level encompasses Category 1 patient management, the areas checked below and similar activities. Requiring a level of training, skill and ability generally associated with persons who are Diplomates of the American Board of Obstetrics and Gynecology and of the sub- specialty board(s) designated below. Subspecialty privileges require additional fellowship training and/or experience in specific patient management problems. A Gynecologic B Maternal and Fetal C Reproductive CAT 3 Special Privileges: Patient management at this level encompasses Categories 1 and 2 (if checked) patient management, the items specifically marked below and similar activities Requiring a level of training, skill and ability generally associated with persons who are Diplomates of the American Board of Obstetrics and Gynecology and who have had additional training and/or experience in specific patient management problems. A Modified radical hysterectomy B Radical hysterectomy C Radical vulvectomy D Pelvic lymphadenectomy E Plastic procedures for the creation of an artificial F Chemotherapy G Implantation 1 Sealed radioactive sources 2 Sacral nerve stimulator http://www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443 1/4

1/3/2018 www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443 H Care of high risk pregnancies I Laser 2 Argon (LASER) 4 CO2 (LASER) 6 Neodymium/YAG (LASER) 8 Other (LASER) J K Vaginal reconstruction (congenital absence) L Tubal ligation reversal M Moderate Sedation (Sedation Module Required prior to granting of privilege) N Fluoroscopy (fluoroscopy supervisor certification required) O Provider performed microscopy (annual competency module required) 1 Urine 2 KOH 3 Wet Prep 4 Fern 5 Pinworm P Videoscopic Surgery 1 Robotic Surgery: Si

a) Xi Surgical System: Certification of Training Required prior to granting of privilege

Q Consultant on End of Life Option a who has specific training to ensure compliance with the UCSF protocol on End Of Life Option. This medical practitioner can accept referrals from other UCSF credentialed providers to assess patient suitability for this Option. CAT 4 Limited Privileges: Patient management limited to the areas specified below. (For members of the Associate Staff, these areas must correspond to written protocols approved by the Credentials Committee of the Medical Staff.)

Privileges limited to practitioners who do not hold American Board of Ob/Gyn certification. Requires a level of training, skill and ability generally associated with persons who are able to perform the procedure. Documentation that additional training and/or experience in the area of the limited privilege reflects current clinical competency. http://www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443 2/4

1/3/2018 www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443 A Midwifery (Applicants must be certified by the American College of Nursemidwifery.) 2 Routine vaginal deliveries (including episiotomy and repair). Antepartum and postpartum care.

http://www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443 3/4

1/3/2018 www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443 Uncomplicated gynecologic outpatient care (including IUD insertion). Internal and external FHR monitoring. Interpretation of NSTs AND CSTs. 02a Antepartum and postpartum care 02b Complicated outpatient gynecologic outpatient care (including IUD insertion). 02c Internal and external FHR monitoring. 02d Interpretation of NSTs and CSTs 3 Fern testing (Provider performed microscopy) 03a Vaginal Wet-Prep (Provider performed microscopy) 03b Urine (Provider performed microscopy) 03c KOH (Provider performed microscopy) 03d Pinworm (Provider performed microscopy) B Routine obstetric and gynecological care of women, including: Routine vaginal deliveries (including episiotomy, low-forceps and low-vacuum extraction) Therapeutic abortion at 13 weeks or less Dilatation and curettage Vulvar, vaginal and cervical biopsy B01 Routine vaginal deliveries (including epistomy, low-forceps and low- vacuum extraction) B02 Therapeutic abortion at 13 weeks or less B03 Dilation and curettage B04 Vulvar, vaginal and cervical biopsy C Routine obstetrics only D Cesarean section in the course of fetal surgery E Cardiac and management only F Clinical Psychology Only G Vulvar, vaginal and cervical biopsy H Colposcopy ADMSE Admitting Services I expect to admit and care for patients under my own name on the following in patient services: OB Obstetrics GY Gynecology GO Gynecology Oncology

PRINT NAME - APPLICANT SIGNATURE DATE http://www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443 4/4

1/3/2018 www.ucsfmedicalcenter.org/medstaffoffice/privilege_form.asp?LINK=443

PRINT NAME - PROCTOR / SUPERVISING PHYSICIAN SIGNATURE - SUPERVISING PHYSICIAN DATE

PRINT NAME - DEPARTMENT CHIEF SIGNATURE - DEPARTMENT CHIEF DATE

PRINT NAME - DEPARTMENT CHAIR SIGNATURE - DEPARTMENT CHAIR DATE

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