Section of Physical Medicine and Rehabilitation

UNIVERSITY HOSPITAL - MCDUFFIE DEPARTMENT OF ORTHOPEDIC SURGERY SECTION OF PHYSICAL MEDICINE AND REHABILITATION REQUEST FOR PRIVILEGES

To be eligible to request clinical privileges, the following threshold criteria must be met.

EDUCATION: MD

TRAINING: Successful completion of an approved residency training program in Physical Medicine and Rehabilitation. Applicant must meet the requirements for board certification outlined in the Medical Staff Bylaws.

EXPERIENCE: The initial applicant must be able to demonstrate training and/or experience on a level commensurate with specialty training from an accredited Physical Medicine and Rehabilitation residency program or current competency in providing medical/surgical management and/or treatment to patients within the scope of core privileges for Physical Medicine and Rehabilitation. Adequate documentation of this performance requires submission of a case list and a reference letter. All initial applicants at completion of residency and/or fellowship must provide an official case list and letter of recommendation assessing performance from the Residency and/or Fellowship Program Director. All initial applicants beyond 12 months of residency/ fellowship completion must provide a case list from the hospital where the applicant has been actively practicing for the last year and a letter of recommendation assessing performance from the hospital’s Chief of Staff or Department Chair.

The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E. according to the Medical Staff Bylaws. Reappointment is based upon unbiased, objective review of result of care according to the hospital’s existing quality mechanisms.

CORE PRIVILEGES: (This list is a sampling of privileges included in the core but is not intended to be an all-encompassing list but rather reflective of the categories/types of privileges included in the core.) REQUESTED GRANTED Admission of patients Evaluation and consultation of neuro-muscular and musculoskeletal disabilities resulting from disease, toxicity, or trauma Prescription for and supervision of the treatment of neuron-musculoskeletal disabilities resulting from disease, toxicity, or trauma Managing and fitting of prosthetics and orthotics Electrodiagnosis Exercises, heat treatment and hydrotherapy Soft tissue, bursa, or joint injections

Applicants requesting any other special privileges listed below must present documentation of training in each privilege requested with a letter from the training director attesting to the applicant’s competence and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff and the Governing Board of University Hospital McDuffie.

SPECIAL PRIVILEGES to include: REQUESTED GRANTED Selective nerve root blocks Epidural injections Moderate Sedation The applicant is required to submit a separate letter of request for any privilege not included on this form. ______Applicant’s Signature Date