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

LABORATORY
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 PROCEDURES GRANTED
WITH DENIED REMARKS
YES NO SUPERVISION
GENERAL (BASIC) PROCEDURES
  Admitting Privileges   
Conscious IV Sedation
  (May require Anesthesia   
approval)
HEMATOPATHOLOGY / IMMUNOHEMATOPATHOLOGY (TRANSFUSION MEDICINE AND TRANSFUSION
SERVICE):

MS-001 (2) Page 1 of 3

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

LABORATORY
Hemoglobin Electrolytes
    
samples reporting
Interpretation and evaluation of
    
special laboratory tests.
CLINICAL CHEMICAL PATHOLOGY:
Interpretation and evaluation of
    
special laboratory tests.
Evaluation of capital
    
equipment

MICROBIOLOGY / SEROLOGY:
Interpretation and evaluation of
    
special laboratory tests
Serology (including special
    
tests)

REQUESTED GRANTED
CLINICAL PROCEDURES GRANTED WITH DENIED REMARKS
YES NO SUPERVISION
TOXICOLOGY:
Interpretation and evaluation of
    
special laboratory tests
HISTOPATHOLOGY
Histopathology samples
    
processing and reporting
BLOOD BANK
  Special Test in Blood Bank   
BLOOD TRANSFUSION AND INFUSION
Infusion (IV Fluids, plasma,
    
etc.)
  Intravenous medicines   
Blood transfusion- including
    
PRBC, FFP Platelet

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.

MS-001 (2) Page 2 of 3

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

LABORATORY

CLINICAL PRIVILEGES APPROVAL

STAMP &
NAME & DESIGNATION DATE
SIGNATURE

Requested by:
_____________________________

Recommended by: Mr. Mahdi M. Al Hadad

Head of Laboratory Department

Dr. Anwer Nehal Ghouri

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

Mr. Ibrahim Hamad Mana Al Amer

Hospital Director

MS-001 (2) Page 3 of 3