‫رشكة نبع الصحة للخدمات الطبية‬

Accident & Emergency Department ‫المملكة العربية السعودية‬

‫قسم الموارد ر‬
‫البشية‬
Application for Clinical Privileges Nabaa Al Saha Medical Services Co.
KSA
HR Administration

Name ID No.

Date of Application _______ / _______ /__________ Expiration Date _______ / _______ /__________

Position Years of Experience

Certification Date _______ / _______ /__________

Specialty Subspecialty
Saudi Council
Date _______ / _______ /__________
Registration No

 BCLS  ACLS  ATLS  PALS  NALS  Other (specify) ___________________________

Clinical Privilege Category :  Temporary  Permanent  Emergency

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.
Head of the Department: Place your initials in the appropriate column. An entry must be made for every item.
N.B.

 A copy of this privilege list will be given to the applicant.

 The original privilege list will be kept in the “Employee File”.
 This list of clinical privileges is for review every two years.

Applicant Credential & Privileges Committee

Clinical Privilege Requested Granted

Yes No Granted with Assist Only
Supervision

  1. History and Physical Examination for

diagnosis of patients
2. Management of patients including treatment
 
plan
  3. Interpretation of ED lab studies
  4. Interpretation of ED imaging studies
  5. Interpretation of Electrocardiograms (ECG)
  6. Resuscitation management for Adult (CPR,
defibrillation, cardio version)
7. Resuscitation management for Pedia (CPR,
 
defibrillation, cardio version)

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 Applicant Credential & Privileges Committee
Clinical Privilege Requested Granted
Yes No Granted with Assist Only
Supervision
8. Airway management for Adult (Airway
  assessment, mouth to mask, bag-valve tent,
oral or naso-pharyngeal airway)
9. Airway management for Pedia (Airway
  assessment, mouth to mask, bag-valve tent,
oral or naso-pharyngeal airway)
  10. Endotracheal Intubation (Adult)
  11. Endotracheal Intubation (Pedia)
12. Anesthesia Technique (Local Anesthesia
 
Only)
  13. Extraction of Arterial Blood Gases sample
  14. Wound skills:
  14.1 Wound dressing
  14.2 Wound debridement
  14.3 Suturing
  14.4 I & D of abscess
  14.5 Foreign body removal
  14.6 Burn dressing
  15. Orthopedic Skills
  15.1 Immobilization
  15.2 Splinting
  15.3 Simple Dislocation Reduction
  16. OB-GYN skills
16.1 Evaluation and Management of
 
emergency cases
  16.2 Deliveries (top emergency)
17. Admitting Patients
18. Peer Review

Acknowledgment of Practitioner
I have requested only those privileges for which, by education, training, current experience and demonstrated
performance. I am qualified to perform, and that I wish to exercise at Al Zahra General Hospital. I also
acknowledge that my professional malpractice insurance extends to all privilege I have requested.
I understand that in exercising any clinical privileges granted, I am constrained by hospital and medical staff
policies and rules applicable generally and any applicable to the particular situation.
________________________________ ______ /______/_____
Employee Number : ________________
Signature of Applicant Date
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 Recommended: Reviewed By :

____________________________________ _____________________________________
Head of the Department Medical Director

Date Date
_____ / _____ /________ _____ / _____ /________

Approved By :

______________________________________
Chairman of Credential Committee ______________________________________
Executive Director General

Date Date
_____ / _____ /________ _____ / _____ /________

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