Delineation Forms

Delineation Forms for Family Medicine

The privilege delineation form should be treated as an administrative tool to assist the applicant's department and/or the credentials/executive committee to determine which privileges the applicant is qualified to obtain.

In non-departmentalized hospitals, medical staff members normally use one form for the entire staff. In departmentalized hospitals, however, it is common for specialty departments to use their own forms.

In hospitals which utilize separate privilege delineation forms for each specialty, family practice should have its own form to minimize difficulty in obtaining privileges. In nondepartmentalized hospitals, family physicians should have input in the design of the privilege delineation form which is used by the medical staff.

Download Delineation Forms

The following documents help develop forms for requesting hospital privileges, and can be modified to suit your needs when establishing standard privileges. They are based upon the core curriculum for family medicine, the program requirements for graduate medical education (ACGME), and reflect the training offered in accredited family medicine residency programs.

Clinical Core Privileges Request without OB(6 page DOC)

Clinical Core Privileges Request with OB(6 page DOC)

Types of Privilege Delineation Forms

The selection of privilege delineation forms should be a local decision, but there are usually four systems used by hospitals to delineate hospital privileges. A hospital may employ the use of one of these systems, or a combination of several.

Privilege List

This term is used to describe a detailed checklist of procedures or conditions. The Joint Commission on Accreditation of Health Care Organizations believes it is not necessary that each hospital use a complicated list of procedures to delineate clinical privileges. The privilege list approach (or a modified form of this approach) may be an effective method for delineating clinical privileges, provided it is flexible.


In this system, treatment areas or procedures are classified either by the degree of complexity of the procedures, illnesses treated, or the level of the physician's training and experience. In any case, categories usually are levels I, II and III; or I, II, III and IV. The Joint Commission believes that when a hospital uses this system in delineation of privileges, the categories must be well-defined and the standards that must be met by the applicant should be clearly stated for each category.

Core Privileging

This method of establishing privileges creates a general description of each specialty and the conditions and procedures commonly addressed by its physicians. This core for a specialty is what an appropriately trained physician with good clinical references should be competent to perform. Such a core for family medicine might read:

"Family Medicine Core Privileges: Admit, evaluate, diagnose, and treat newborns, childrens and adults for most illnesses and injuries. Privileges include but are not limited to: pre-and post-operative care, suture simple lacerations, I&D abscess, perform simple skin biopsy or excision, remove non-penetrating corneal foreign body, and manage uncomplicated minor closed fractures and uncomplicated dislocations."


This system refers to a format in which the applicant describes the privileges requested. Rather than a checklist or categorical system, this method requires applicants to list what they can and cannot do in their own words; e.g., all abdominal surgery, no kidney surgery. This system may be modified by exceptions or by additional/special privileges.