Lexington Medical Center
Clinical Privileging in
PATHOLOGYApplicant's Name______________________________________________
Date________
Minimum formal training: The applicant must be able to demonstrate
successful completion of an anatomic and/or clinical pathology residency
training program accredited by the Accreditation Council for Graduate Medical
Education (ACGME) or an American Osteopathic Association-approved pathology
residency training program.
Required previous experience: The applicant must be able to demonstrate
that he or she has been actively involved in the clinical practice of pathology
during the past 12 months.
Special Requests: Successful, documented completion of approved,
recognized course (s) when such exists, or acceptable supervised training in
residency, fellowship, or other acceptable experience.
Reappointment Requirements: Demonstrated current competence, evaluation
evidence to include quality improvement activities and outcomes, by way of
adequate volume of current experience with acceptable results in the privileges
requested.
If you meet the above criteria, you may request privileges in Pathology.
CORE PRIVILEGE FORM
Certified American Board of Pathology --
Anatomic
YES___ NO___
Clinical YES___ NO___
Forensic YES___ NO___
Other _________________ Recertification
Date______________
The minimum education, training, and experience qualifications are as
delineated above and in the Medical Staff By Laws, Rules and Regulations, and
policies. Please see these documents for full information.
To request Core Privileges, please check the appropriate column, striking
through any text that doesn't apply.
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CLINICAL PATHOLOGY (CP) CORE PRIVILEGES |
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Privileges include hematology
diagnoses and consults (preparation and interpretation of peripheral blood
and bone marrow samples and other special hematologic tests), coagulation
diagnoses and consults, blood banking diagnoses and consults, microbiology
diagnoses and consults, immunoserological diagnoses and consults, chemistry
diagnoses and consults (to include interpretation of electrophoresis
patterns, lipid, endocrine, and hepatic profiles, and other special
chemistry tests). On-call and emergency involvement are an expected and
given capability in all areas of CP. When on-call, capable of handling
initial disposition of anything in specialty. |
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ANATOMIC PATHOLOGY (CAP) CORE PRIVILEGES |
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Privileges include
gross examination and neoplastic and non-neoplastic diagnoses of surgical
and biopsy specimens to include diagnoses and consults in neuropathology,
dermatopathology, lymphoreticular, head and neck, pulmonary, mediastinal,
soft tissue, gastrointestinal, musculoskeletal, cardiovascular, endocrine,
hepatobiliary, renogenitourinary, and hematology with preparation and
interpretation of bone marrow biopsy sections. Privileges also include
emergency intra-operative and surgical specimen consultations with or
without frozen section, cytopathology diagnoses and consult, medical
(non-forensic) autopsy diagnoses and consult, and preparation and
interpretation of immunofluorescent and immunohistochemistry testing of
surgical and biopsy specimens. On-call and emergency involvement are an
expected and given capability in all areas of CAP.
When on-call, capable
of handling initial disposition of anything in specialty. |
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SPECIAL PRIVILEGES (CATEGORY A)
Require adequate documentation of experience and
proficiency. |
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Complete diagnosis of
muscle biopsies (enzymes, etc.) |
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Complete diagnosis of renal biopsies
(LM, FM, EM, etc.) |
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Fine needle aspiration cytology procedure,
superficial |
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Fine needle aspiration cytology diagnostic
interpretation |
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Bone marrow aspiration and biopsy procedure |
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Bone marrow aspiration and biopsy diagnostic
interpretation |
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Complete neuropathology biopsy diagnosis |
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Forensic pathology practice |
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Hemotherapy/pheresis therapy |
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Skin biopsy procedure |
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Complete skin biopsy interpretation, to include
DIF |
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Examination and interpretation, endocrine
challenge test |
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Non-emergent complex coagulation consults |
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Prostate needle biopsy interpretation |
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SPE/IFE serum protein interpretation |
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Hemochromatosis case management |
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Other: |
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SPECIAL PRIVILEGES (CATEGORY B -- available to Active
Staff pathologists only)
Require documentation of experience and proficiency. |
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General lab program: lab directorship, division
directorship, section directorship |
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Capital equipment/instrumentation: planning,
selection, budget, negotiation |
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Personnel selection, deployment and leadership |
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Research, evaluation, selection and
implementation of new tests |
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QA, QC, and/or continuous quality improvement
program leadership |
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Reference lab work, selection and utilization
of labs |
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Lab safety and preventive maintenance and
leadership |
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Lab inspection and accreditation direction and
leadership |
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CMC and other peripheral lab directing an
leadership |
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Other: |
In making application for the above requested (checked) privileges, I attest
to the requisite training and experience for the procedure and/or item.
Furthermore, I understand that Lexington Medical Center and its medical staff,
by long custom (and, possibly, contractually) and in order to assure consistent
and timely practice, limits primary utilization of the above privileges to the
active staff or those working with or in behalf of the active staff.
___________________________________________________
Applicant's Signature
Unless specifically excepted, the checked privileges are individually
considered and approved at the department chief review and other LMC entities
and affiliates to the extent they are available.
___________________________________________________
___________
Department Chief Date
Adopted: 5/96 Reviewed/Revised: 1/97, 1/98, 1/99, 3/99, 5/00, 5/02, 5/04
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