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    Application For Clinical Privileges Pediatric: Instructions To Applicant

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    HujiLoko
    The document is an application for clinical privileges at a pediatric facility. It lists general pediatric privileges and special privileges the applicant can request, including procedures like ventilator management, endotracheal intubation, and cancer chemotherapy. It also lists general procedures like lumbar puncture, bladder catheterization, and inserting arterial and central venous lines. The applicant must sign to state they are competent in the requested privileges and procedures.

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    Application For Clinical Privileges Pediatric: Instructions To Applicant

    Uploaded by

    HujiLoko
    19 views1 page
    The document is an application for clinical privileges at a pediatric facility. It lists general pediatric privileges and special privileges the applicant can request, including procedures like ventilator management, endotracheal intubation, and cancer chemotherapy. It also lists general procedures like lumbar puncture, bladder catheterization, and inserting arterial and central venous lines. The applicant must sign to state they are competent in the requested privileges and procedures.

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    Pediatric

    Original Title

    8 Pediatric

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    The document is an application for clinical privileges at a pediatric facility. It lists general pediatric privileges and special privileges the applicant can request, including procedures like ventilator management, endotracheal intubation, and cancer chemotherapy. It also lists general procedures like lumbar puncture, bladder catheterization, and inserting arterial and central venous lines. The applicant must sign to state they are competent in the requested privileges and procedures.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    19 views1 page

    Application For Clinical Privileges Pediatric: Instructions To Applicant

    Uploaded by

    HujiLoko
    The document is an application for clinical privileges at a pediatric facility. It lists general pediatric privileges and special privileges the applicant can request, including procedures like ventilator management, endotracheal intubation, and cancer chemotherapy. It also lists general procedures like lumbar puncture, bladder catheterization, and inserting arterial and central venous lines. The applicant must sign to state they are competent in the requested privileges and procedures.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Name:

    APPLICATION FOR
    CLINICAL PRIVILEGES
    Date :
    PEDIATRIC

    INSTRUCTIONS TO APPLICANT:
    Please check [√] the privileges and procedures which you are requesting. By checking these privileges and procedures you are
    also stating that you believe yourself to be competent and experienced in each. Sign and date at the end of the form.

    GENERAL PRIVILEGES SPECIAL PRIVILEGES


    General Pediatric Privileges Exchange transfusion
    Neonatology privileges Ventilator management
    Consultation in Subspecialty Elective endotracheal intubation
    1. Elective cardioversion
    Insertion of peripheral alimentation line
    Pericardiocentesis
    GENERAL PROCEDURES
    Subdural tap
    ALL OF THE BELOW Ventricular shunt tap
    Lumbar puncture Cancer chemotherapy ( peds oncology only)
    Suprapubic bladder aspiration Peripherals venous cutdown
    Bone Marrow aspiration/ biopsy
    Bladder catheterisation
    Paracentesis OTHERS
    Thoracocentesis
    Thoracostomy tube replacement
    Insertion of arterial line (umbilical)
    Insertion of arterial line (peripheral)
    Insertion of central venous line
    Intra- osseous access

    **Privileges to perform emergency lifesaving procedures are automatically granted to all staff physicians.

    Signature of Applicant Date:

    Signature of Facility CMS Date:

    Name of facility

    Signature of Group Medical Director Date:

    Verification and comments (if any):

    NU/TRIAL/JULY12
    MED020/AUG12
    PAGE 1 OF 4
    Page 1of 1

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