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MSF Anatomic Clinical Pathology

This document outlines the privileges and requested clinical procedures for a pathology provider. It lists Category I pathology privileges including general surgical pathology, neuropathology, autopsy pathology, and clinical pathology subspecialties. The provider must acknowledge their qualifications and training to perform the requested privileges. The department chair then reviews and makes recommendations, and the request requires approval from the credential committee, medical executive committee, and board of directors.

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Alfia Mawaddah
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115 views2 pages

MSF Anatomic Clinical Pathology

This document outlines the privileges and requested clinical procedures for a pathology provider. It lists Category I pathology privileges including general surgical pathology, neuropathology, autopsy pathology, and clinical pathology subspecialties. The provider must acknowledge their qualifications and training to perform the requested privileges. The department chair then reviews and makes recommendations, and the request requires approval from the credential committee, medical executive committee, and board of directors.

Uploaded by

Alfia Mawaddah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Delineation Of Privileges

Anatomic & Clinical Pathology

Provider Name:

Privilege Requested Tabled Approved

PATHOLOGY - CATEGORY I PRIVILEGES

Criteria:
a) Board Certification or qualified for certification by the American Board of Pathology; OR,
b) Successful completion of an ACGME or AOA approved Pathology training program requiring certification by a
Training Director regarding experience and demonstrated competence to perform the procedure(s) being requested.

Proctoring Requirements: A minimum of eight (8) cases, in accordance with the Medical Staff Proctoring Protocol.

PATHOLOGY - CATEGORY I PRIVILEGES:

General Surgical Pathology: ___ ___ ___

a) Routine - gross and microscopic ___ ___ ___

b) Frozen sections ___ ___ ___

c) Emergency consultation (i.e. OR consultation with/without frozen section diagnosis) ___ ___ ___

d) Cytology - cervical, vaginal ___ ___ ___

e) Cytology - special (fluids, sputum, urine) ___ ___ ___

f) Cytology - needle aspirations ___ ___ ___

Neuropathology ___ ___ ___

Autopsy pathology (adult and pediatric) ___ ___ ___

Clinical Pathology: ___ ___ ___

a) Blood banking ___ ___ ___

b) Clinical chemistry ___ ___ ___

c) Hematology ___ ___ ___

d) Microbiology ___ ___ ___


e) Sample collection: ___ ___ ___

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Delineation Of Privileges
Anatomic & Clinical Pathology

Provider Name:

Privilege Requested Tabled Approved

1) Bone Marrow ___ ___ ___

2) Fine needle biopsy ___ ___ ___

ACKNOWLEDGEMENT OF THE PRACTITIONER:


I have requested only those privileges for which my education, training, current experience and demonstrated
performance I am qualified to perform, and that I wish to exercise at Huntington Hospital, and I understand that: a) in
exercising my 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.

Signature of Applicant: ___________________________________ Date:___________________________

DEPARTMENT CHAIR 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.

Applicant may perform privileges and procedures as indicated: _______ YES _______ NO

Exceptions/Limitations (Please Specify): ______________________________________________________________

APPROVALS:

Department Chair: __________________________________ Date: __________

Credential Committee Approved on: _____________

Medical Executive Committee Approved on: _____________

Board of Directors Approved on: _____________

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