AHP - Nurse Practitioner Privileges Form

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Alicia Jefferson
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1 AHP - Nurse Practitioner Privileges Form MEDS MEDICATIONS Administer, dispense and prescribes drugs and provides treatment within the NP s scope of practice, as designated in the standardized formulary and consistent with the NP s skill, training, competence, professional judgment and policies of the medical center. (Refer to appendix A) Current Licensure as NP in the state of California Current state furnishing license and/or federal drug enforcement agency certificate with Schedules II-V Gener Contr CORE BASIC Maintenance of NP License, Furnishing Certificate and DEA license General Formulary Controlled Substance Formulary alty Formulary Anticoagulants Antipscyhotics Antiseizure Biological and Immunological Agents Blood Modifiers Hematopoietic TPN/Lipid Transplant Immunosuppressants Chemotherapy General Anesthetics (Standardized Procedures Required) Neuromusclar Blocking Agents (For Critical Care areas only and must be competent in airway management) Sedation Agents (Standardized Procedures Required) CORE PRIVILEGES CORE NP PRIVILEGES These privileges apply to all NP's. Initial and ongoing assessment of a patientï ½s medical, physical and psychosocial status including: 1. Completing History & Physical 2. Developing a treatment plan 3. Making daily rounds at direction of supervising physician 4. Recording of progress notes as per required by the medical center policies and 1/19

2 procedures. 5. Ordering diagnostic tests, and therapeutic modalities, such as medications, treatments and, examinations Initiating referral to appropriate physician or other healthcare professional 7. Instructing, educating and counseling patients and families concerning health status, results of tests, disease process and discharge planning. 8. Writing of discharge summaries as mandated by HIMS. 9. Ordering Rehab and Respiratory Therapy. 10. Including establishing primary and secondary diagnoses as well as determining complication, comorbidities, and present on admission (POA) conditions. 11. Ordering Durable Medical Equipment 12. Ordering Home Health Services Does not include admitting privileges. Formal Training: Successful completion of an NP program National Certification: Current certification by the American Nursing Association (American Nurses Credentialing Center- ANCC) or the American Academy of Nurse Practitioners Certification (AANP) OR by a predecessor or successor agency or actively seeking certification and achieving it on the first examination for which applicant is eligible BLS or ACLS/PALS as required. Assessment of Competency will be conducted by the supervising physician or designee until the level of performance is determined to be satisfactory. Maintenance of National Certification Continuing Medical Education: Documentation of compliance with the Board of Registered Nursing of California CEU requirements for re-licensure. Educational activities must relate, in part, to the privileges requested and granted. Competency Assessment: Current demonstrated competence and documentation of successful treatment to a minimum of patients, set forth by the Chair/Chief of Department, for the past 24 months based on results of quality assessment/improvement activities and outcomes. Maintain online Procedure log (elog). IP OP ADLT PEDS NEON OBTA Inpatient Outpatient Adult (Including Adolescent Patient) Pediatrics (including Adult Patients with congenital disorders and/or diseases) Neonatology OBTAINING BLOOD CONSENTS 2/19

3 ORDE EMERG ORDERING MED/SURG RESTRAINTS Emergency Medicine - Patients of all ages: Assess acute patients excluding trauma alerts and Codes. If assessment warrants, a physician is immediately involved in the case. Performs procedures as directed by emergency medicine physician for acute patients. (ONLY IF YOU WORK FOR THE EMERGENCY DEPARTMENT) - National NP certification within 1 year of hire date. - Current BLS/ ACLS or PALS certification - Maintenance of BLS/ACLS/PALS certification 10 Abscess Identification Ultrasound Standardized Procedure Ten (10) observed procedures. Reappointment Criteria: Three (3) procedures per year. 20 Bladder Volume Ultrasound Standardized Procedure Ten (10) observed procedures. Reappointment Criteria: Three (3) procedures per year. 30 Intravenous Access Ultrasound Standardized Procedure Ten (10) observed procedures. Reappointment Criteria: Three (3) procedures per year. PICU CRITICAL CARE PEDIATRICS (neonatal, infants, children and adolescents). Provide primary and specialty care for children from birth to 21 years of age or until transfer to Adult Services in the areas of health promotion, maintenance and restoration; includes children with acute illness, chronic and congenital diseases and disabilities. PEDT BLS certification; PALS for Critical Care PNP; California RN/NP license Maintenance of BLS/PALS certification as require Maintain online electronic procedure log PEDIATRIC EMERGENCY TRANSPORT For patients being admitted to a Pediatric Unit, from age birth to 18 years. Includes both air and ground transport, as well as medical management at 3/19

4 referring hospital. Demonstrated competence in Intubation, Arterial Line placement, Thoracentesis, and Chest Tube Placement before completion of orientation and going on transport without preceptor. Approval by PNP Medical director Current BLS, PALS, and NRP Certification Orientation to transport Maitenance/Renewal Criteria: Maintain transport case review and QA. Maintain advanced practice skill NENA NEONATOLOGY Initial and ongoing assessment of pediatric patients in the Intensive Care Nursery for the patientsï ½ medical, physical and psychosocial status including: taking and recording history, analyzing history and physical information to develop an appropriate differential diagnosis, ordering and interpreting diagnostic tests, physical and occupational therapies, examination. Administration of medications and performing advanced procedures and delivery room resuscitation. Instruct, educate and counsel families concerning health status, results of tests, disease process and discharge planning, writing/dictating of discharge summaries, initiate referral to appropriate physician or other healthcare professional Completion of a Masterâ s prepared NNP program National Board Certification by NCC as NNP required within one (1) year of hire Current BLS/ NRP certification Minimum 2 month orientation and direct precepting by an experienced NNP Maintenance/Renewal Crieria: Maintenance of BLS/NRP/PALS certification as required Maintain online electronic procedure log NEED NEONATAL EMERGENCY TRANSPORT For patients being admitted to the ICN or with corrected gestational age of up to 6 months. Includes both air and ground transport, as well as medical management at referring hospital. Demonstrated competence in Intubation, Arterial Line placement, Thoracentesis, and Chest Tube Placement before completion of orientation and going on transport without preceptor Current BLS and NRP Certification 4/19

5 Orientation to transport Maintain transport case review and QA maintain advanced practice skill RADI RADIOLOGY Documented training and experience in radiology 10 RADIOLOGY Competency Assessment: Current demonstrated competence and documentation of successful treatment to a minimum number of patients, set forth by the Chair/Chief of Department, for the past 24 months based on results of quality assessment-improvement activities and outcome 20 INTERVENTIONAL RADIOLOGY PPM Provider Performed Microscopy Competency Test Required PPM PPM PPM PPM PPM STAN_ Annual Competency Test Required Urine KOH Pinworm Wet Prep Fern STARDIZED PROCEDURES 10 Alteplase use for Management of Pleural and Abdominal Effusions (Adult, Peds) 20 Anal Dilation (Neonatal, Peds) 30 Arterial Line Placement (Adult) 5/19

6 40 Baclofen Pump Reprogram and Refill 50 Bone Marrow Aspiration (Adult, Peds) 60 Botulinum Toxin Therapy (Adult, Peds) 70 Bronchoscopy (Adult, Peds) 80 Cardiac Stress - Dobutamine Infusion (Adult) 25 Procedures 50 Procedures 81 Cardiac Stress Testing Myocardial Perfusion- Pharmacological Infusion with A2a agonist agents (Peds) 5 Procedures Maintenance Renewal: 10 Procedures 82 Cardiac Stress Testing Myocardial Perfusion- Pharmacological Infusion with A2a agonist agents (Adults) 25 Procedures Maintenance Renewal: 50 Procedures 83 Cardiac Stress- Exercise Testing (Adult) 25 Procedures Maintenance/Renewal Criteria 50 Procedures 84 Cardiac Stress-Exercise Testing (Peds) 20 Procedures 6/19

7 Maintenance/Renewal Criteria 40 Procedures 90 Cautery of Granulation Tissue (Adult, Neonatal, Peds) 100 Central Line Placement and Temporary Non-tunneled Dialysis Catheter Insertion (Adult, Peds) Intial Criteria: 10 Procedures Online Competency Module for CVC Placement and Removal Maintenance/Renewal Criteria 10 Procedures 101 Subclavian 5 Procedures 5 Procedures / Year 102 Internal Jugular 5 Procedures 5 Procedures / Year 103 Femoral Lines 5 Procedures 5 Procedures / Year 104 Quinton 5 Procedures 5 Procedures / Year 110 Central Line Removal (Adult, Peds) Online Competency Module for CVC Placement and Removal 7/19

8 120 Central Venous Catheter Removal, tunneled (Adult, Peds) Online Competency Module for CVC Placement and Removal 130 Chemotherapy (Adult, Peds) 3 Months of Orders Cosigned 40 Orders 140 Chest Tube Placement (Adult) 3 procedures 150 Chest Tube Removal (Adult, Peds) 160 Closing a Wound (Adult, Peds) 170 Colposcopy (Adult, Peds) 50 Procedures 40 Procedures 180 Cryosurgery (Adult, Peds) 190 Cystoscopy (Adult, Neonatal, Peds) 8/19

9 195 Diagnostic Head and Neck Ultrasonography 200 Drain Removal (Adult, Neonatal, Peds) 210 Ductal Lavage (Adult, Peds) 220 Dysplasia Assessment and Treatment (Adult, Peds) 230 Endometrial Biopsy (Adult, Peds) 240 Endotracheal Intubation (Adult) 10 Procedures 20 Procedures 250 Episiotomy and Laceration Repair (Adult, Peds) 260 EVD Removal (Adult, Peds) 270 EVD Troubleshooting (Adult, Peds) 9/19

10 280 Femoral Venous Blood Draw (Adult, Peds) 290 Fine Needle Aspiration (Adult, Peds) 300 Gastrostomy (non-peg) Replacement (Neonatal, Peds) 310 Gastrostomy (PEG) tube replacement (Neonatal, Peds) 320 GCRC Anal Squamous IRC (Adult, Peds) 325 Greater Occipital Nerve (GON) Injection (Adult,Peds) 330 Hepatic Arterial Infusion of Chemo (Adult, Peds) 340 High Resolution Anoscopy (HRA) (Adult, Peds) 50 Procedures 100 Procedures 350 Iliac Crest Bone Graft (Adult, Peds) 10/19

11 360 Implanon Insertion (Adult, Peds) Etonogestrel requires completion of the clinical training program from Merck prior to performing insertion of the subcutaneous implant. 370 Implanon Removal (Adult, Peds) 380 Incision and Drainage (Adult, Neonatal, Peds) 390 Infrared Coagulation Therapy (Adult, Peds) 10 Procedures 50 Procedures 400 Injection of corticosteroid into granulation tissue (Neonatal, Peds) 410 Instrumentation Removal (Adult, Peds) 420 Intra-articular Injection (Adult, Peds) 11/19

12 430 Intralesional Biotherapy (Adult, Peds) 440 Intraventricular Chemo Via Ommaya Reservoir (Adult, Peds) 450 IUD Insertion (Adult, Peds) 460 Joint Aspiration (Adult, Peds) 470 Lap Band Port Access (Adult, Peds) 480 Lingual Frenotomy (Neonatal, Peds) 490 Liver Biopsy (Adult, Peds) 20 Procedures 20 Procedures 500 Lumbar Drain Insertion (Adult, Peds) 510 Lumbar Puncture (Adult, Peds) 12/19

13 520 Lumbar Puncture/Intrathecal Baclofen (Adult, Peds) 530 Lumbar Puncture-Intrathecal Chemotherapy (Adult, Peds) 540 Lumbar Subarachnoid Catheter Removal(Adult, Peds) 550 Medication Instillation into EVDs (Adult, Peds) 570 Myringotomy (Adult, Peds) 580 Nasopharyngoscoopy and Nasal Endoscopy (Adult, Peds) 590 Neonatal Chest Tube Removal (Neonatal) 600 Neonatal Exchange Transfusion (Neonatal) 13/19

14 610 Neonatal Intubation (Neonatal) 620 Neonatal Lumbar Puncture (Neonatal) 630 Neonatal Paracentesis (Neonatal) 640 Neonatal/Pediatrics Chest Tube Placement (Neonatal, Peds) 650 Neonatal/Pediatrics Intraosseous Line Placement (Neonatal, Peds) 660 Neonatal/Pediatrics Peripheral Arterial Line Insertion (Neonatal, Peds) 670 Neonatal/Pediatrics Thoracentesis (Neonatal, Peds) 680 Neonatal Umbilical Vessel Catheterization (Neonatal) 14/19

15 685 Onabotulinum Toxin Type A (BOTOX) Injections (Adult) 690 Otomicroscopy (Adult, Peds) 700 Pediatric Endotracheal Intubation (Pediatric) 6 procedures/year 710 Percutaneous Placement or Replacement of Catheter or Tube Suture (Adult, Peds) 720 Peritoneal Paracentesis (Adult, Peds) 560 Moderate Sedation (Adult, Neonatal, Peds) 3 months and Self Competency Test Required 10 Orders 730 Prog. Codman Hakim PS Medical STRATA Programmable Shunt Valves (Adult, Peds) 740 Radial Artery Harvest (Adult) 15/19

16 750 Restraint-Ordering Medical Surgical Restraints (Adult, Peds) 760 RN First Assist (Adult, Peds) RN First Assist Certificate 770 Rubber Band Ligation for Hemorrhoids (Adult, Peds) 780 Saphenous Vein Harvesting (Adult) 790 Sedated Pedi Lung Function Testing (Neonatal, Peds) 20 Procedures 20 Procedures 800 Skin Biopsy (Adult, Peds) 810 Spinous Process Removal (Adult, Peds) 820 Stem Cell Infusion (Adult, Peds) 16/19

17 830 Stoller Afferent Nerve Stimulation (SANS) (Adult, Peds) 835 Subcutaneous Medication Implant Insertion (Adult, Peds) Etonogestrel requires completion of the clinical training program from Merck prior to performing insertion of the subcutaneous implant. 836 Subcutaneous Medication Implant Removal (Adult, Peds) Etonogestrel requires completion of the clinical training program from Merck prior to performing insertion of the subcutaneous implant. 840 Subdural Evacuating Port System Drain Removal (Adult, Peds) 850 Surgical Incision (Adult, Peds) 860 Temp Pacer Wire Removal (Adult, Peds) 870 Thoracentesis (Adult) 17/19

18 880 Tracheostomy Replacement (Adult, Neonatal, Peds) 890 Transthoracic Line Removal (Adult, Neonatal, Peds) 900 Trigger Point Injections (Adult, Peds) 910 Urodynamic Assessment (Adult, Neonatal, Peds) 930 Vulvar or Perineal Perianal Biopsy (Adult, Peds) 920 Ventricular Septal Defect Closure Assist (Neonatal, Peds) 10 Procedures 20 Procedures 960 Videostroboscopy 940 Withdrawing CSF from Ventricular Shunt or Reservoir (Adult, Neonatal, Peds) 950 Wound Debridement (Adult, Neonatal, Peds) 18/19

19 PRINT NAME - APPLICANT SIGNATURE DATE PRINT NAME - PROCTOR / SUPERVISING PHYSICIAN SIGNATURE - SUPERVISING PHYSICIAN DATE PRINT NAME - DEPARTMENT CHIEF SIGNATURE - DEPARTMENT CHIEF DATE PRINT NAME - DEPARTMENT CHAIR SIGNATURE - DEPARTMENT CHAIR DATE 19/19

VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR SPECIAL PRIVILEGES ADVANCED PRACTICE PROVIDER PROFESSIONAL STAFF WITH PRIVILEGES (PSP)

VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR SPECIAL PRIVILEGES ADVANCED PRACTICE PROVIDER PROFESSIONAL STAFF WITH PRIVILEGES (PSP) FOR ADVANCED PROCEDURE S Advanced Procedure Privileges: Are those approved procedural privileges requiring additional education and training and may be granted only upon evidence of initial and ongoing