Biographical sketch, kathy matzka, cpmsm, cpcs



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Modified Core Example Family Medicine


Qualifications

To be eligible to apply for privileges in family medicine, the applicant must meet the following criteria:

Training:

MD or DO with successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in family medicine. (Does not apply to current medical staff appointees.)



Board Certification

One of the following requirements must be met:

1. Current certification in family medicine by the American Board of Family Medicine or the American Osteopathic Board of Family Physicians; or

2. Actively seeking Board certification with achievement of certification within 1 year of appointment.



Board certification requirements do not apply to any practitioner already a member of the Medical Staff as of _____________________.
Required previous experience
Applicants for initial appointment or initial privileges must be able to demonstrate adequate experience reflective of the scope of privileges requested in order for the medical staff to make a reasoned decision regarding the competency of the practitioner.
Reappointment requirements
To be eligible to renew privileges in family medicine, the applicant must demonstrate current demonstrated competence and an adequate volume of experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation, monitoring through the Medical Staff Quality Improvement Program, and patient care outcomes.
Privileges Requested

Applicant Instructions: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges. Your ability to perform each procedure/privilege will be assessed. Requests for privileges not included on this form should be made in writing and include documentation of training and experience. Please check only the boxes reflective of your practice specific to this hospital. The procedures and privileges listed on this form reflect what most physicians with specified training and experience can request & the hospital can support.
 Referring Staff Category Privileges - Refer patients to the Hospital for outpatient testing and/or procedures and refer patients to Active Staff members or Hospitalists for inpatient treatment. (Referring Staff may visit their referred patients in the Hospital, review patients’ medical records and receive information concerning patients’ medical condition and treatment, but may not participate in any inpatient treatment or make any entries in the medical record.)
Applicants for Refer and Follow category are not eligible to request additional privileges. Stop here and review and sign the Acknowledgment section of this form.

 Active Staff Privileges - > 2 patient admissions per month or > 24 per year

 Courtesy Staff Privileges - < 2 patient admissions per month or < 24 per year

 Consulting Staff Privileges - Evaluate, diagnose, treat, and provide consultation to adolescent and adult patients on request of an Active or Courtesy Staff member.


Adult Medicine Privileges/Procedures - The privileges below include the specific procedure requested and such other procedures that are extensions of the same techniques and skills.

 Admit, evaluate, diagnose, treat, and provide consultation to adolescent and adult patients; assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services; provide care to patients in the intensive care setting; performance of history and physical exam; care of the normal newborn and uncomplicated premature infant equal to or greater than 36 weeks gestation.

 Arthrocentesis and joint injection

 Bone marrow aspiration/biopsy

 Burns, superficial and partial thickness

 I & D abscess

 Local anesthetic techniques

 Lumbar puncture

 Manage uncomplicated minor closed fractures and uncomplicated dislocations

 Osteopathic manipulative treatment using isotonic, isometric forces

 Perform simple skin biopsy or excision

 Peripheral nerve blocks

 Placement of anterior and posterior nasal hemostatic packing

 Remove nonpenetrating foreign body from the eye, nose, or ear

 Suture uncomplicated lacerations

 Vasectomy

 Administration of Conscious Sedation and Analgesia

Additional Qualifications for Conscious Sedation and Analgesia:



  • Initial applicants must complete Qualifying Examination for Sedation/Analgesia

  • For recredentialing, must have performed a minimum of ten (10) cases per year within the two (2) year reappointment period (total of 20 cases) OR must retake and successfully pass the Qualifying Examination for Sedation/Anesthesia.



Pediatric Privileges/Procedures - The privileges below include the specific procedure requested and such other procedures that are extensions of the same techniques and skills.
 Newborn Circumcision

 I & D abscess

 Lumbar puncture

 Manage uncomplicated minor closed fractures and uncomplicated dislocations

 Perform simple skin biopsy or excision

 Remove nonpenetrating corneal foreign body

 Suture uncomplicated lacerations

 Administration of Conscious Sedation and Analgesia

Additional Qualifications for Conscious Sedation and Analgesia:


  • Initial applicants must complete Qualifying Examination for Sedation/Analgesia

  • For recredentialing, must have performed a minimum of ten (10) cases per year within the two (2) year reappointment period (total of 20 cases) OR must retake and successfully past the Qualifying Examination for Sedation/Anesthesia.


Gynecology Privileges/Procedures - The privileges below include the specific procedure requested and such other procedures that are extensions of the same techniques and skills.
 Biopsy of cervix, endometrium

 Colposcopy

 Cryosurgery/cautery for benign disease

 Diagnostic cervical dilation and uterine curettage

 Excision/biopsy of vulvar lesions

 Incision and drainage of Bartholin duct cyst or marsupialization

 Insertion and removal of intrauterine devices

 Removal of foreign body from vagina

 Suturing of uncomplicated lacerations

 Uterine curettage following incomplete abortion


Obstetrical Privileges/Procedures- The privileges below include the specific procedure requested and such other procedures that are extensions of the same techniques and skills.

 Amniotomy

 Attendance at delivery to assume care of normal newborns

 Augmentation of labor

 Cesarean section

 D&C including suction and postpartum

 Excision of vulvar lesions at delivery

 External and internal fetal monitoring

 Induction of labor, medical

 Induction of labor, rupture of membranes

 Initial management of post partum hemorrhage (PPH)

 Investigative OB ultrasound for presentation only

 Management of prenatal and postpartum care

 Management of uncomplicated labor including normal spontaneous vaginal delivery or a term vertex presentation

 Manual removal of placenta, post delivery

 Normal spontaneous vaginal delivery

 Oxytocin challenge test

 Post partum endometritis

 Pudendal anesthesia

 Repair of episiotomy—first, second, and third degree

 Repair of vaginal lacerations

 Vacuum assisted delivery


Acknowledgement of Practitioner

I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform, for which my professional liability insurance will cover, and that I wish to exercise at [Hospital Name]. I understand that:

a. In exercising any 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 situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.

c. If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience.

Signature: _______________________________ Date: _________________

Department Chair's Recommendation

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s):

 I recommend all requested privileges.

 I recommend privileges with the following conditions/modifications (include explanation):





Privilege

Condition(s)/Modification(s)/Explanation











 I do not recommend the following requested privileges (include explanation):




Privilege

Condition(s)/Modification(s)/Explanation












_______________________________________ ___________________

Department Chair Signature Date
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