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    MS-001 (2) Clinical Priv Form Pediatrician 2019

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    Athira Rajan
    The document is an application for clinical privileges in pediatrics at Bader al-Janoub General Hospital in Najran, Saudi Arabia. It lists various clinical procedures and requests the applicant to indicate which procedures they are requesting privileges for. It also provides columns for the hospital to indicate whether requested privileges are granted, granted with supervision, or denied. Procedures listed include admitting privileges, IV access, sedation, newborn care procedures, intubation, lumbar puncture, blood transfusion, and administration of IV medications. If privileges are granted with supervision or denied, remarks can be included. Privilege lists are reviewed every 2 years or as necessary.

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    MS-001 (2) Clinical Priv Form Pediatrician 2019

    Uploaded by

    Athira Rajan
    89 views4 pages
    The document is an application for clinical privileges in pediatrics at Bader al-Janoub General Hospital in Najran, Saudi Arabia. It lists various clinical procedures and requests the applicant to indicate which procedures they are requesting privileges for. It also provides columns for the hospital to indicate whether requested privileges are granted, granted with supervision, or denied. Procedures listed include admitting privileges, IV access, sedation, newborn care procedures, intubation, lumbar puncture, blood transfusion, and administration of IV medications. If privileges are granted with supervision or denied, remarks can be included. Privilege lists are reviewed every 2 years or as necessary.

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    12. MS-001 (2) CLINICAL PRIV FORM PEDIATRICIAN 2019

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    The document is an application for clinical privileges in pediatrics at Bader al-Janoub General Hospital in Najran, Saudi Arabia. It lists various clinical procedures and requests the applicant to indicate which procedures they are requesting privileges for. It also provides columns for the hospital to indicate whether requested privileges are granted, granted with supervision, or denied. Procedures listed include admitting privileges, IV access, sedation, newborn care procedures, intubation, lumbar puncture, blood transfusion, and administration of IV medications. If privileges are granted with supervision or denied, remarks can be included. Privilege lists are reviewed every 2 years or as necessary.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    89 views4 pages

    MS-001 (2) Clinical Priv Form Pediatrician 2019

    Uploaded by

    Athira Rajan
    The document is an application for clinical privileges in pediatrics at Bader al-Janoub General Hospital in Najran, Saudi Arabia. It lists various clinical procedures and requests the applicant to indicate which procedures they are requesting privileges for. It also provides columns for the hospital to indicate whether requested privileges are granted, granted with supervision, or denied. Procedures listed include admitting privileges, IV access, sedation, newborn care procedures, intubation, lumbar puncture, blood transfusion, and administration of IV medications. If privileges are granted with supervision or denied, remarks can be included. Privilege lists are reviewed every 2 years or as necessary.

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    © All Rights Reserved
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    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


    PEDIATRICS
    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   

    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


    PEDIATRICS
    Sedation
    (May require
    Anesthesia approval)
    PEDIATRIC PRIVILEGES
    CATEGORY 1 (Non-
      pediatrician specialty   
    consultant)
    CATEGORY 2 -
    Illness or problem with
    no apparent serious
    threat to life (usually
      granted to family   
    practitioners or other
    physician with 6-12
    months pediatric
    training).

    REQUESTED GRANTED
    CLINICAL
    GRANTED WITH DENIED REMARKS
    YES NO PROCEDURES
    SUPERVISION
    CATEGORY
    CATEGORY 1 -
      Normal term newborn –   
    2500 grams or more.
    CATEGORY 2 - Low
    birth weight infants -
        
    <2500 gram without
    complications
    CATEGORY 3 - All
    newborn infants
      (excluding continuing   
    vent support) with life
    threatening illnesses.
    SURGICAL AND DIAGNOSTIC PROCEDURE

    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


    PEDIATRICS
    Intubation (specify
        
    inclusive ages_____)
        
    Peripheral venous cut-
        
    down
    Intraosseous needle
        
    placement
    Peripheral arterial
        
    puncture
      Lumbar puncture   
      Chest tube insertion   
      Suprapubic tap   
      ECG recording   
    Naso Oro gastric
        
    insertion
    Peripheral vein
        
    cannulation sampling
    Urine Analysis & Stool
        
    Analysis
      Testing for VP shunting   
    NEONATOLOGY
      Neonatal Resuscitation   
      Nasogastric Tube insertion   
      Neonatal Intubation   
    Survanta Administration
    Umbilical V & A insertion
    BLOOD TRANSFUSION AND INFUSION
    Infusion ( IV Fluids,
        
    plasma, etc.)
      Intravenous medicines   
    Blood transfusion- whole,
        
    packed cells

    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


    PEDIATRICS
    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


    STAMP &
    NAME & DESIGNATION DATE
    SIGNATURE

    Requested by:
    ___________________________

    Dr. Mohammad Elsayed


    Recommended by:
    Head of Pediatrics Department

    Dr. Anwer Nehal Ghouri


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

    Mr. Ibrahim Mana Al Amer


    Hospital Director

    MS-001 (2) Page 4 of 4

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