Privileging Anaesth List (All) & Log Book (MO) - QEH

QEH/PENG(K)/05/PIND.
00(2019)
CORE PROCEDURE SKILLS FOR PRIVILEGING
DEPARTMENT OF ANAESTHESIOLOGY & INTENSIVE CARE
1.) NAME OF APPLICANT :
2.) DATE OF COMPLETION OF HOUSEMANSHIP :
3.) HOSPITAL OF HOUSEMANSHIP TRAINNING :
4.) DATE REPORT TO QEH (TARIKH LAPOR DIRI KE HQE):
5.) CATEGORY : CONSULTANT / SPECIALIST / GAZETTEMENT / MEDICAL OFFICER / MEDICAL ASSITANT / NURSE / MLT / OTHERS ( Please Specify)
6.) NSR CERTIFICATE NO. (Please attach hard copy with the form) :
7.) CREDENTIALING CERTIFICATE NO. (Please attach hard copy with the form} :
8.) APPLICATION FOR : NEW / RENEWAL / ADDITIONAL
ii.) OBSERVE iii.) ASSIST iv.) PERFORMED PROCEDURES

a.) MINIMAL
a.) REQUIREMENT OF b.) ACTUAL
NO. i.) CORE PROCEDURE SKILLS b.) ACTUAL a.) REQUIRED NO. OF b.) ACTUAL ASSISTED REQUIREMENT FOR
OBSERVED PERFORMED
OBSERVATION DONE ASSIST PROCEDURES PROCEDURES DONE PERFORMED
PROCEDURES PROCEDURES DONE
PROCEDURES
1 Mask Holding Technique - - - - 100
2 Head Tilt Chin Lift & Jaw Trust Maneuver - - - - 100
3 Airway Management Orotracheal & Nasotracheal Intubation - - - - 100
4 LMA / Pro-seal Insertion - - - - 30
5 Cricothyrotomy - - - - -
6 Setting Peripheral Lines - - - - 100
7 Central Venous Cannulation - - - - 20
IV Lines
8 Intraarterial Cannulation - - - - 40
9 Insertion of Pulmonary Artery Flotation Catheter (Swan Ganz) - - - - -
10 Regional AnaestheticTechniques Local Infiltration - - - - 100
11 Interscalene Brachial Plexus Block - - - - 5
12 Supraclavicular Brachial Plexus Block - - - - 3
13 Axillary Brachial Plexus Block - - - - 5
14 Peripheral Nerve Block: Upper Limb Intercostal Nerve Block - - - - -
15 Ulnar, Median & Radial Nerve Block - - - - 5
16 Wrist Block - - - - 5
17 Digital Nerve Block Of Finger - - - - 50
18 Sciatic Nerve Block - - - - 50
19 Femoral, Obturator & Lateral Cutaneous Nerve Block - - - - 50
20 3 in 1 Block - - - - 50
21 Tibial Nerve Block - - - - 10
Peripheral Nerve Block: Lower Limb
22 Common Peroneal Nerve block - - - - -
23 Saphenous Nerve Block - - - - 5
24 Deep Peroneal Nerve Block - - - - -
25 Digital Nerve Block Of Toe - - - - -
26 Intercostal Nerve Block - - - - -
27 Interpleural Local Anaesthesia - - - - -
Thorax & Abdomen
28 Paravertebral Nerve Block - - - - -
29 Pudendal Nerve Block - - - - -
30 Epidural: Lumbar & Thoracic Approach - - - - 10
31 Central Neural Blockage Caudal Block - - - - 100
32 Spinal Anaesthesia - - - - 50
33 Sympathetic Nerve Block Stellate Ganglion Block - - - - -
34 Insertion Of Chest Tube - - - - 50
35 Pericardiocentesis - - - - -
36 Bronchoscopy - - - - 10
Other Procedures
37 Cardiopulmonary Resuscitation With Defibrillation - - - - 2
38 Percutaneus Tracheostomy - - - - 10
39 Double Lumen Tube Insertion - - - - 2
*Please attach: Certified by

1. Privileging form
2. Log book (for new & additional procedures)
QEH/PENG(K)/05/PIND.00(2019)
6.) FULL REGISTRATION CERTIFICATE NO. (Please attach hard copy with the form) :
ii.) OBSERVE iii.) ASSIST iv.) PERFORMED

ANAESTHESIOLOGY CORE PROCEDURES FOR MEDICAL OFFICERS a.) MINIMAL
NO. a.) REQUIREMENT OF b.) ACTUAL OBSERVATION a.) REQUIRED NO. OF b.) ACTUAL ASSISTED REQUIREMENT FOR b.) ACTUAL PERFORMED
DIRECTLY OBSERVED PROCEDURAL SKILLS & COMPULSORY
OBSERVED PROCEDURES DONE ASSIST PROCEDURES PROCEDURES DONE PERFORMED PROCEDURES DONE
PERFORMED PROCEDURES
PROCEDURES
Operation Theatre:
1 Pre-Medication and Assessment 10 10 10
2 Checking Anaesthetic Equipment 2 2 10
3 Monitored Sedation 5 5 10
4 Mask Ventilation 5 5 20
5 Intravenous Induction 10 10 20
6 Gaseous Induction 10 10 20
7 Oral Intubation 5 5 20
8 Nasal Intubation 5 5 20
9 Laryngeal Mask Insertion & Spontaneous GA 5 5 10
10 Maintenance of Anaesthesia 10 10 20
11 Reversal From Anaesthesia 10 10 20
12 Spinal Anaesthesia 5 5 10
13 Arterial Line Insertion 2 2 10
14 Central Venous Catheter Insertion 2 2 10
15 Monitoring in Recovery 10 10 20
16 APS Management 10 10 20
NON CORE PROCEDURES
1 Lumbar Epidural 5 5 10
2 Epidural Anaesthesia 2 2 5
3 Preparing Patient Control Analgesia Machine 2 2 10
4 Fiberoptic Bronchoscopic Intubation 10 10 5
5 Nerve Block 2 2 10
Intensive Care Unit:
1 Ventilation - IPPV 10 10 20
2 Ventilation - NIV 10 10 20
3 Weaning and Extubation 10 10 20
4 Cerebral Resuscitation 10 10 20
5 Transporting Critically Ill Patient 10 10 20
6 Anaesthesia Outside OT (eg. MRI, CT, Endoscopy, ECT, ESWL etc) 10 10 20
7 Endotracheal Suctioning 10 10 10
8 Nebuliser Preparation and Application 2 2 10

1. Privileging form
3. MMC full registration cert copy
QEH/PENG(K)/05/PIND.00(2019)
6.) FULL REGISTRATION CERTIFICATE NO. (Please attach hard copy with the form) :
ii.) OBSERVE iii.) ASSIST iv.) PERFORMED PROCEDURES
NO. i.) CORE PROCEDURE SKILLS a.) REQUIREMENT OF a.) REQUIRED NO. OF ASSIST b.) ACTUAL ASSISTED a.) MINIMAL REQUIREMENT FOR b.) ACTUAL PERFORMED
b.) ACTUAL OBSERVATION DONE
OBSERVED PROCEDURES PROCEDURES PROCEDURES DONE PERFORMED PROCEDURES PROCEDURES DONE
1 e.g. Pre-medication and Assessment 1 1 20
1. Privileging form

ANAESTHESIOLOGY CORE PROCEDURES
1 Pre-Medication And Assessment O=Observe A=Assist P=Perform
S/N Patient’s Name Date R/N Diagnosis Outcome Remarks
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
1 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
2 Certified by
2 Checking Anaesthetic Equipment O=Observe A=Assist P=Perform
1 O
2 O

1 A
2 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
3 Certified by
3 Monitored Sedation O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O

1 A
2 A
3 A
4 A
5 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
4 Certified by
4 Mask Ventilation O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O

1 A
2 A
3 A
4 A
5 A
5 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
6 Certified by
5 Intravenous Induction O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
7 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
8 Certified by
6 Gaseous Induction O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
9 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
10 Certified by
7 Oral Intubation O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O

1 A
2 A
3 A
4 A
5 A
11 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
12 Certified by
8 Nasal Intubation O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O

1 A
2 A
3 A
4 A
5 A
13 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
14 Certified by
9 Laryngeal Mask Insertion & Spontaneous GA O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O

1 A
2 A
3 A
4 A
5 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
15 Certified by
10 Maintenance of Anaesthesia O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
16 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
17 Certified by
11 Reversal From Anaesthesia O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
18 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
19 Certified by
12 Spinal Anaesthesia O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O

1 A
2 A
3 A
4 A
5 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
20 Certified by
13 Arterial Line Insertion O=Observe A=Assist P=Perform
1 O
2 O

1 A
2 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
21 Certified by
14 Central Venous Catheter Insertion O=Observe A=Assist P=Perform
1 O
2 O

1 A
2 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
22 Certified by
15 Monitoring In Recovery O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
23 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
24 Certified by
16 APS Management O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
25 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
26 Certified by
ANAESTHESIOLOGY NON CORE PROCEDURES
1 Lumbar Epidural O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O

1 A
2 A
3 A
4 A
5 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
27 Certified by
2 Epidural Anaesthesia O=Observe A=Assist P=Perform
1 O
2 O

1 A
2 A

1 P
2 P
3 P
4 P
5 P
28 Certified by
3 Preparing Patient Control Analgesia Machine O=Observe A=Assist P=Perform
1 O
2 O

1 A
2 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
29 Certified by
4 Fibreoptic Bronchoscopic Intubation O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
30 Certified by
1 P
2 P
3 P
4 P
5 P
31 Certified by
5 Nerve Blocks O=Observe A=Assist P=Perform
1 O
2 O

1 A
2 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
32 Certified by
ANAESTHESIOLOGY INTENSIVE CARE PROCEDURES
1 Ventilation - IPPV O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
33 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
34 Certified by
2 Ventilation - NIV O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
35 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
36 Certified by
3 Weaning and Extubation O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
37 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
38 Certified by
4 Cerebral Resuscitaion O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
39 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
40 Certified by
5 Transporting Critically Ill Patient O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
41 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
42 Certified by
6 Anaesthesia Outside OT (e.g. MRI, CT, Endoscopy, ECT, ESWL etc) A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O
1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
43 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
11 P
12 P
13 P
14 P
15 P
16 P
17 P
18 P
19 P
20 P
44 Certified by
7 Endotracheal Suctioning O=Observe A=Assist P=Perform
1 O
2 O
3 O
4 O
5 O
6 O
7 O
8 O
9 O
10 O

1 A
2 A
3 A
4 A
5 A
6 A
7 A
8 A
9 A
10 A
45 Certified by
1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
46 Certified by
8 Nebuliser Preparation and Application O=Observe A=Assist P=Perform
1 O
2 O

1 A
2 A

1 P
2 P
3 P
4 P
5 P
6 P
7 P
8 P
9 P
10 P
47 Certified by

Privileging Anaesth List (All) & Log Book (MO) - QEH

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QEH/PENG(K)/05/PIND.

ii.) OBSERVE iii.) ASSIST iv.) PERFORMED PROCEDURES

*Please attach: Certified by

ii.) OBSERVE iii.) ASSIST iv.) PERFORMED

*Please attach: Certified by

ii.) OBSERVE iii.) ASSIST iv.) PERFORMED PROCEDURES

1 e.g. Pre-medication and Assessment 1 1 20

*Please attach: Certified by

2. Log book (for new & additional procedures)

1 Pre-Medication And Assessment O=Observe A=Assist P=Perform

2 Checking Anaesthetic Equipment O=Observe A=Assist P=Perform

2 Checking Anaesthetic Equipment O=Observe A=Assist P=Perform

3 Monitored Sedation O=Observe A=Assist P=Perform

3 Monitored Sedation O=Observe A=Assist P=Perform

4 Mask Ventilation O=Observe A=Assist P=Perform

5 Intravenous Induction O=Observe A=Assist P=Perform

6 Gaseous Induction O=Observe A=Assist P=Perform

7 Oral Intubation O=Observe A=Assist P=Perform

8 Nasal Intubation O=Observe A=Assist P=Perform

9 Laryngeal Mask Insertion & Spontaneous GA O=Observe A=Assist P=Perform

ANAESTHESIOLOGY CORE PROCEDURES

10 Maintenance of Anaesthesia O=Observe A=Assist P=Perform

11 Reversal From Anaesthesia O=Observe A=Assist P=Perform

12 Spinal Anaesthesia O=Observe A=Assist P=Perform

12 Spinal Anaesthesia O=Observe A=Assist P=Perform

13 Arterial Line Insertion O=Observe A=Assist P=Perform

13 Arterial Line Insertion O=Observe A=Assist P=Perform

14 Central Venous Catheter Insertion O=Observe A=Assist P=Perform

14 Central Venous Catheter Insertion O=Observe A=Assist P=Perform

15 Monitoring In Recovery O=Observe A=Assist P=Perform

16 APS Management O=Observe A=Assist P=Perform

1 Lumbar Epidural O=Observe A=Assist P=Perform

1 Lumbar Epidural O=Observe A=Assist P=Perform

2 Epidural Anaesthesia O=Observe A=Assist P=Perform

2 Epidural Anaesthesia O=Observe A=Assist P=Perform

3 Preparing Patient Control Analgesia Machine O=Observe A=Assist P=Perform

3 Preparing Patient Control Analgesia Machine O=Observe A=Assist P=Perform

4 Fibreoptic Bronchoscopic Intubation O=Observe A=Assist P=Perform

5 Nerve Blocks O=Observe A=Assist P=Perform

5 Nerve Blocks O=Observe A=Assist P=Perform

1 Ventilation - IPPV O=Observe A=Assist P=Perform

2 Ventilation - NIV O=Observe A=Assist P=Perform

3 Weaning and Extubation O=Observe A=Assist P=Perform

4 Cerebral Resuscitaion O=Observe A=Assist P=Perform

5 Transporting Critically Ill Patient O=Observe A=Assist P=Perform

7 Endotracheal Suctioning O=Observe A=Assist P=Perform

8 Nebuliser Preparation and Application O=Observe A=Assist P=Perform

8 Nebuliser Preparation and Application O=Observe A=Assist P=Perform

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