Kingdom of Saudi Arabia

‫المملكة العربية السعودية‬

MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

ANESTHESIA DEPARTMENT
NAME: EMPLOYEE NUMBER:
ID NUMBER: YEARS OF EXPERIENCE:
SAUDI COUNCIL REGISTRATION #: DATE OF EXPIRATION:

Designation:

 RESIDENT  SPECIALIST  CONSULTANT

Certification/s:
 BCLS  ACLS  ATLS  PALS  Other/s (please specify)________________

Clinical Privilege Category:

 TEMPORARY  APPROVED  EMERGENCY
At the time of a life-threatening clinical emergency, any Practitioner may render whatever care he/she believes to
be indicated regardless of the extent of his/her granted privileges.

Instructions:
APPLICANT: In the first column below, place a check in the appropriate box whether you have requested for the
privileges listed on the second column.
GENERAL INSTRUCTION: Please tick () in the appropriate column whether the privileges that the applicant
applied for is “GRANTED”, “GRANTED WITH SUPERVISION” or “DENIED”. (If the requested privileges
are either “GRANTED WITH SUPERVISION” or “DENIED”, the “REMARKS” column may be necessary to be
filled up).
Note: A copy of this privilege list will be given to the applicant. The original privilege list will be kept in the
“Personnel File”. The Clinical Privilege of Medical Staffs will be reviewed every 2 years along with their Annual
Evaluation for Contract Renewal or as necessary. (For New Medical Staffs, review of privilege will be after 90
days from the start of employment.)

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION
GENERAL (BASIC) PROCEDURES
  Admitting Privileges   
  Conscious IV Sedation   
MS-001 (2) Page 1 of 4
Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

ANESTHESIA DEPARTMENT
(May require Anesthesia
approval)
CORE PRIVILEGES
Local Infiltration
    
Anesthesia
  Topical Anesthesia   
Pre-operative,
Intraoperative and Post
    
Operative Care of
Patients
Management of General
    
Anesthesia
Management of Spinal
    
Anesthesia
Management of Epidural
    
Anesthesia
Management of Qudal
    
Anesthesia

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION
CORE PRIVILEGES - CONTINUATION
Management of
    
Intravenous Anesthesia
Management of
    
Resuscitation
Management of Fluid,
Electrolyte and
  Metabolic and   
Hemodynamic
Disturbance
  Post Operative Pain   
Management by
Continuous Epidural

MS-001 (2) Page 2 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

ANESTHESIA DEPARTMENT
Infusion Technique
Manage the Anesthesia
    
Clinic
MANAGEMENT OF GENERAL ANESTHESIA FOR:
  General Surgery   
  ENT Surgery   
  Orthopedic Surgery   
  Urology   
  Emergency Cases   
Endotracheal Tube
    
Insertion
Difficult Intubation
    
Cases
MANAGEMENT OF PATIENT REQUIRING MECHANICAL RESPIRATORY SUPPORT:
Internal
  Jugular/Subclavian/Fe   
moral Cannulation
Percutaneous
    
Tracheostomy
BLOOD TRANSFUSION AND INFUSION
Infusion ( IV Fluids,
    
plasma, etc.)
  Intravenous medicines   
Blood transfusion- whole,
    
packed cells

If at any stage you wish to perform any surgical or therapeutic procedure that is not listed in this application, you
must refer to the Credentialing and Privileging Committee.

CLINICAL PRIVILEGES APPROVAL

MS-001 (2) Page 3 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

ANESTHESIA DEPARTMENT
STAMP &
NAME & DESIGNATION DATE
SIGNATURE

Requested by:
Anesthesiologist

Recommended by: Dr. Anwer Nehal Ghouri

Head of Department

Dr. Anwer Nehal Ghouri

Medical Director/
Medical Credentialing & Privileging
Approved by: Committee Chairman

Mr. Ibrahim Hamad Mana Al Amer

Hospital Director

MS-001 (2) Page 4 of 4