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Organized Medical Staff At Lexington Medical Center(LCHSD)
Department Of Pathology And Laboratory Medicine
Delineation Of Privileges Form

Lexington Medical Center
Clinical Privileging in

Applicant'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.

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.


  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.


  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.


Require adequate documentation of experience and proficiency.

Complete diagnosis of muscle biopsies (enzymes, etc.)
  Complete diagnosis of renal biopsies (LM, FM, EM, etc.)
  Fine needle aspiration cytology procedure, superficial
  Fine needle aspiration cytology diagnostic interpretation
  Bone marrow aspiration and biopsy procedure
  Bone marrow aspiration and biopsy diagnostic interpretation
  Complete neuropathology biopsy diagnosis
  Forensic pathology practice
  Hemotherapy/pheresis therapy
  Skin biopsy procedure
  Complete skin biopsy interpretation, to include DIF
  Examination and interpretation, endocrine challenge test
  Non-emergent complex coagulation consults
  Prostate needle biopsy interpretation
  SPE/IFE serum protein interpretation
  Hemochromatosis case management


SPECIAL PRIVILEGES (CATEGORY B -- available to Active Staff pathologists only)
Require documentation of experience and proficiency.

  General lab program: lab directorship, division directorship, section directorship
  Capital equipment/instrumentation: planning, selection, budget, negotiation
  Personnel selection, deployment and leadership
  Research, evaluation, selection and implementation of new tests
  QA, QC, and/or continuous quality improvement program leadership
  Reference lab work, selection and utilization of labs
  Lab safety and preventive maintenance and leadership
  Lab inspection and accreditation direction and leadership
  CMC and other peripheral lab directing an leadership

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

(posted 19 April 2005)