Pediatrics

Privilege Check List

Name
Address

Phone

Certified
Name of University

Date

Name of College

Date

Expiration

Training & Courses

Institution

Date

Saya menyatakan bahwa saya kompeten untuk menangani kasus-kasus yang kompleks
di bidang spesialisasi saya termasuk melayani konsultasi dari dokter-dokter lain.
Saya juga menyatakan kompeten untuk melakukan prosedur teknis seperti tercatat
di bawah ini sebagai bagian dari kewenangan klinis (clinical priveleges).
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Date

Applicant

Date

Department of Pediatrics

PRIVILEGES
Privilege
Desired

Chairman
Approval
Allergic Disorder
1. Uncomplicated Asthma
2. Complicated Asthma
3. Serum Sickness
Cardiovascular
1. Hypertension
2. Congenital Heart Disease
3. Rheumatic Heart Disease
4. Subacute Bacterial Endocarditis
5. Management of Failure
6. Cardiac Regulators
Diseases of Blood and Blood Forming Organs
1. Leukemia
2. Aplastic Anemia
3. Hemolytic Anemia
4. Hemophilia
5. Iron Deficiency Anemia Requiring Transfusion
Disturbance of Water and Electrolyte Balance
1. Mild
2. Moderate
3. Severe
Endocrine Metabolite Disorders
1. Diabetes, Uncomplicated
2. Diabetes, in Severe Acidosis
3. Diseases of Thyroid
4. Diseases of Adrenal Gland
Full Term Infant Care with Complications
1. Life Threatening: Surgical
2. Life Threatening: Medical
3. Non-Life Threatening: Surgical
4. Non-Life Threatening: Medical
Medical Pediatric Care Uncomplicated Infections of :
1. Respiratory Tract
2. Gastrointestinal Tract
3. Genitourinary
4. Skin
5. Peripheral Nervous System
6. Complicated Infections of Same
7. Fever of Undetermined Origin
8. Central Nervous System Infections

PRIVILEGES (continued)
Privilege
Desired

Chairman
Approval
Minor Surgical Procedures
1. I&D Abscess
2. Circumcison
3. Spinal Tap
4. Cut Down
5. Subdural Tap
6. Thoracentesis
7. Paracentesis
8. Pericardiocentesis
9. Total Parenteral Alimentation
10. Arterial Blood Gas Sampling
Miscellaneous
1. Lipodystrophies
2. Collagen Diseases
3. Juvenite Rheumatoid Arthritis
4. Nephritis & Nephrosis
5. Emotional Disorders
6. Disturbances of Growth & Development
7. Steroid Therapy Over 1 Week Duration
8. Kawasakis Disease
9. Child Abuse (MANDATORY)
Neurology Procedures
1. EEG
2. Evoked Potentials
3. EMG
Consultations
1. Behavioral & Emotional Disorders in Children
2. Disorders of Nerves & Muscles
3. Infection of Nervous System
4. Seizure Disorder
5. Disorders of Development
6. Neurological Disorders of Newborns
7. Trauma of Nervous System
Nursery Privileges
Routine newborn care
Premature Infant Care
1. Without Complications over 4 lbs
2. Without Complications under 4 lbs
Premature Infant Care with Complications
1. Life Threatening: Surgical
2. Life Threatening: Medical
3. Non-Life Threatening: Surgical
4.

Non-Life Threatening: Medical

PRIVILEGES (continued)
Privilege
Desired

Chairman
Approval
Pulmonary Disease
1. Bronchopulmonary Dysplasia
2. Cystic Fibrosis
3. Hypoventilation Syndrome
4. Central
5. Peripheral
6. Tracheostomy
7. Asthma
8. Reccurent Pneumonias
9. Respiratory Failure
10. Acute
11. Chronic