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Contra Costa Regional Medical Center
CNM Privileges Request Form
Practitioner: _____________________________________
CNM Page 1 of 2
06/2009 * Separate proctoring required. Department(s) Number
Privilege Description
D=With Direct Supervision
C=With Consultation
U=Unrestricted D/C/U Training/ Education Experience Current Competence Requested Granted D=Denied P=Pending CNM=Criteria Not Meet
OBSTETRICS & GYNECOLOGY
FAM OBG
1
Outpatient management of low risk prenatal
patient
C CA lic. or FNP
PA or CNM N/A N/A
U CA lic. or FNP
PA or CNM 30 10 cases in
last 4yrs.
FAM OBG
2
Outpatient management of high risk prenatal
patient
C
CA lic. or FNP
PA or CNM
OBG 1
N/A N/A
U
CA lic. or FNP
PA or CNM
OBG 1
30 10 cases in
last 4 yrs.
FAM
OBG
4
Antepartum, intrapartum and postpartum
management of pregnancy with minor
complications (such as mild pre-eclampsia,
prior cesarean section) and uncomplicated
vaginal delivery including amniotomy,
episiotomy, second degree laceration repair
and manual removal of placenta*
D
CA lic. or CNM
Recommend NRP
certification
30 N/A
U
FP or OB.
Recommend NRP
certification or
50 8 cases in
last 2 yrs. &
CME in fetal
monitoring
within last 2
yrs.
CNM or CA lic.
Recommend NRP
certification
100
Name and date of CME course which included Fetal Monitoring:
__________________________________________________________________________________
FAM
OBG
5 Antepartum fetal heart rate monitoring
D CA lic. FNP
or CNM N/A N/A
U CA lic FNP
or CNM 30 8 cases in
last 4 yrs.
FAM OBG
6
Basic 3rd trimester Obstetrical ultrasound
including viability, placenta location, fetal
number, and amniotic fluid index*
D CA lic. FNP
or CNM N/A N/A
U CA lic. FNP
or CNM 10 4 cases in
last 2 yrs.
FAM OBG
9 Induction or augmentation of labor
C CA lic.
or CNM N/A N/A
U CA lic.
or CNM 10 1 case in
last 2 yrs.
FAM OBG
18 Implanon insertion and removal U CA lic. or
FNP, PA or CNM
& Training
N/A N/A
Contra Costa Regional Medical Center
CNM Privileges Request Form
Practitioner: _____________________________________
CNM Page 2 of 2
06/2009 * Separate proctoring required. Department(s) Number
Privilege Description
D=With Direct Supervision
C=With Consultation
U=Unrestricted D/C/U Training/ Education Experience Current Competence Requested Granted D=Denied P=Pending CNM=Criteria Not Meet FAM
OBG
19 IUD insertion and removal
D CA lic. or
FNP, PA or CNM N/A N/A
U CA lic. or
FNP, PA or CNM 5 N/A
FAM
OBG
19a Suction Endometrial Biopsy
D CA lic. or FNP
or CNM N/A N/A
U CA. Lic. or FNP
or CNM 5 N/A
OBG
34
Caring for and discharging uncomplicated post
partum patients (for providers without delivery
privileges).
C CA Lic. FNP
or CNM N/A N/A
U
FP or OB N/A 20 in last
2 yrs
CA Lic. FNP
or CNM 50 20 in last
2 yrs
OBG
35
Basic first and second trimester ultrasound for
dating, viability, and location of pregnancy. U
CA Lic. FNP
or CNM
4 hours of training
in residency, or
ultrasound course
15 10 in last
2 yrs.
PED
11
Inpatient uncomplicated newborn care (e.g. normal
term newborn and those with indirect billirubin <15)
C CA Lic., FNP, PA,
PNP or CNM N/A N/A
U CA Lic., FNP, PA,
PNP or CNM 20 3 cases in
last 2 yrs.
OBG
3a
Women’s Health Care Maintenance
Health care maintenance of women including
physical exams and contraception, vaginitis, and
STD’s (for FNPs or CNMs without adult medicine
privileges).
C CA lic. or FNP
or CNM N/A N/A
U CA lic. or FNP
or CNM N/A 1 yr. in
last 4 yrs.
OBG
3b
General Women’s Health Care
Women’s health problems usually cared for by a
generalist such as, irregular bleeding, evaluation of
pelvic pain, GU, and breast problems (for FNPs or
CNMs without medicine privileges).
C CA lic. or FNP
or CNM N/A N/A
U CA lic. or FNP
or CNM N/A 1 yr. in
last 4 yrs.
OBG
Assist at C-Sections U CNM N/A N/A
I certify that I have reviewed the Contra Costa Regional Medical Center Privilege Criteria, and that I meet the specified criteria for
education/training, experience, and current competence for the privileges, which I have indicated above.
_____________________________________________________ _____________________________________________________
Signature of Requesting Practitioner Date Signature of Department Chairperson Date