DELINEATION OF CLINICAL PRIVILEGES

Photograph

RESIDENT MEDICAL OFFICER

Name: Department: _______________________________

Date of Privileging:_____________ Date Of Joining: _______________ Experience in current field: ______________

Qualifications: __________________________________________________________________________________

Applicant: In the first columns below, place a check in the appropriate box for each privilege listed below.
A Yes or No response must be entered for every item.
Chairperson: Place your initials in the appropriate column. An entry must be made for every item.

PRIVILEGING: (Kindly tick the appropriate box)

First time privileging
Renewal without additional privileging request
Renewal with request of new privileges (credentials attached for new privileges)

Granted
Yes No Clinical Privilege Requested Granted with Denied
Supervision
  Privileges to perform emergency life-saving procedure are
automatically granted to all physicians.
CORE PRIVILEGES:
  Assess, work-up and provide initial treatment to patients who
present in the ER / ICU with any minor illness or injury, condition
or symptom. Privileges do not include long-term care of on an in-
patient basis.
  Scope of services includes the evaluation, diagnosis and
management of patients of all ages presenting with non-life-
threatening illness or injury.
  Procedures performed include minor wound management and
repair, incision and drainage of abscesses, reductions of simple
digital fracture/dislocations, extremity splinting, foreign body
removal from skin, subcutaneous tissue, nose, ears and eyes,
local anaesthesia, arthrocentesis and lumbar puncture.
  Administer and manage sedation with the intent to depress
consciousness, often with associated loss of airway reflexes,
depressed respiratory and cardiovascular function.
  Administration of thrombolytic therapy of myocardial infarction
and stroke.
  Airway Noninvasive positive pressure ventilation, Bag-valve-mask
ventilation, Laryngeal mask airway insertion, Esophageal
obturator airway insertion and oral airway insertion.
Ascitic tapping
  Aspiration Arthrocentesis (small & large joint, excluding hip) and
Bursal aspiration.
  Bladder decompression and catheterisation techniques
  Blood and blood component transfusion therapy

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 DELINEATION OF CLINICAL PRIVILEGES
RESIDENT MEDICAL OFFICER (contd.)

Name:

Granted
Yes No Clinical Privilege Requested Granted with Denied
Supervision
  Cardiac
 ECG interpretation,
 Emergency D.C. cardioversion and defibrillation,
 External transcutaneous pacemaker use and
 Closed cardiopulmonary resuscitation.
  Cricothyrotomy
  Emergency ultrasound
  ENT
 Nasal packing,
 Cautery for epistaxis,
 Paratonsillar abscess aspiration and incision and drainage
 Evacuation of septal and auricular hematomas.
Endotracheal Intubation
  Fluid, electrolyte management
  Fluorescein exam of the eye
  Frenulotomy
  Gastrointestinal Anoscopy and Hernia reduction.
  Genitourinary Suprapubic tap/catheterization.
  GI decontamination and lavage
  Gynecologic evaluation of prepubertal and postpubertal females
  I & D abscess/hematoma
  I & D peritonsillar abscess
  Injections
 Local and regional anesthesia; Intercostal nerve block,
Peripheral nerve block below elbow and knee, Infraorbital,
supraorbital, mental, inferior alveolar/lingual nerve blocks for
regional anesthesia.
 Local injection for tendonitis/bursitis and contrast injection for
imaging.
  Interpretation of antibiotic levels and sensitivities
  Insertion of peripheral and central venous access
  Intra-cardiac injection
  Intraosseous insertion and infusion
  Irrigation and management of caustic exposures
  Laryngoscopy – direct and indirect
  Lumbar puncture

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 DELINEATION OF CLINICAL PRIVILEGES
RESIDENT MEDICAL OFFICER (contd.)

Name:

Granted
Yes No Clinical Privilege Requested Granted with Denied
Supervision
  Miscellaneous
 Parenteral medication administration,
 Interpretation of the results of radiographic studies,
 Point of care focused ultrasound (FAST, Aortic Caliber,
Emergency Cardiac and Procedural).
 Additional imaging: initial ordering and preliminary evaluation
of CT and MRI studies.
  Management of epistaxis
  Nail wedge excision/nailbed repair
  Nasogastric / Orogastric intubation
  Neurology
 Lumbar puncture (adult and child) and Spine immobilization.
  Ophthalmologic
Slit lamp examination with direct and indirect opthalmoscopy,
tonometry, Corneal foreign body removal and rust ring removal.
  Orthopedics
 Reduction of dislocations involving the phalanges,
metacarpals, metatarsals, patella and shoulder.
 Initial management including restorative reduction of displaced
and nondisplaced fractures involving the clavicles, ribs,
phalanges, metacarpals, metatarsals, carpal bones, tarsal
bones, radius, ulna, humerus, tibia, fibula, nasal bone and
patella.
  Order chemical / physical restraint to agitated patients
  Order respiratory services
  Order rehab services
  Oxygen therapy
  Paracentesis
  Perform simple skin biopsy or excision (foreign body removal)
  Perform history and physical exam
  Perform waived laboratory testing not requiring an instrument,
including but not limited to fecal occult blood, urine dipstick, and
vaginal pH by paper methods
  Placement of anterior and posterior nasal hemostatic packing
  Placement of intravenous lines
  Placement of NG tube
  Perichondrial haematoma incision and drainage
  Pericardiocentesis
  Pericardial tapping

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 DELINEATION OF CLINICAL PRIVILEGES
RESIDENT MEDICAL OFFICER (contd.)

Name:

Granted
Yes No Clinical Privilege Requested Granted with Denied
Supervision
  Peripheral venous cutdown
  Peritoneal lavage
  Preliminary interpretation of imaging studies
  Psychiatric
 Rapid tranquilization of agitated and psychotic patients.
  Puncture cannulation – artery and vein
  Surgery
 Initial management of 1o, 2o burns less than 20%, BSA, Simple
and complex multilayer laceration repair,
 Repair of nail bed lacerations.
 Repair of the wounds of the deep fascia or muscle,
 Repair of wounds of the eyelids, nose, ear, face, or lip,
extensor tendon repairs, abscess incision and drainage, nail
trephination, and external hemorrhoidectomy.
  Remove non-penetrating foreign body from the eye, nose, or ear
  Removal of ingrown toenail
  Reduction & splinting/casting of uncomplicated minor closed
fractures & uncomplicated dislocations
  Replacement of tracheostomy tube
  Silver nitrate cauterization
  Spine immobilisation
  Thoracentesis
  Thoracostomy tube insertion
  Tracheostomy
  Tympanocentesis
  Uncomplicated gastrostomy tube replacement / management
  Use of reservoir masks and continuous positive airway pressure
masks for delivery of supplemental oxygen, humidifiers,
nebulizers, and incentive spirometry
Variceal / non-variceal hemostasis
  Venipuncture
  Wound care and closure uncomplicated lacerations
SPECIAL PRIVILEGES:
  Administration Of Sedation And Analgesia
  Echocardiography

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 DELINEATION OF CLINICAL PRIVILEGES
RESIDENT MEDICAL OFFICER (contd.)

Name:

Granted
Yes No Clinical Privilege Requested Granted with Denied
Supervision
  Fibre-optic laryngoscopy
  Supra-pubic bladder tap
  Telehealth
ANY OTHER PRIVILEGES
 
 

I hereby certify that I am sound by physical & mental health.

__________________________________ _______________ _____________

_______________

Signature of Applicant Regd. Number Code Number Date

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 DELINEATION OF CLINICAL PRIVILEGES
RESIDENT MEDICAL OFFICER (contd.)

Name:

Do Not Write Below This Line

It is recommended that Dr. _____________________________________________ be granted the

Clinical Privileges as sought and requested in the above document and appointed as

_______________________________________ in the Department Of

____________________________ _______________________________________ w.e.f.

___________________ to __________________.

RECOMMENDED BY REVIEWED BY

______________________________________ _______________________________________
HOD – Medical Services C.O.O.
DATE: ______________________ DATE: ______________________

APPROVED BY

______________________________________
Chairperson – Credentialing & Privileging Committee / Managing Director

DATE: ______________________