DATE S PHYSICIAN NAME ****************************************************************************** I request the following clinical privileges, and I am aware that a denial of privileges relating to a practitioner's professional competence or professional conduct will result in the hospital submitting a report to the National Practitioner Data Bank. APPLICANT: Check the requested column for the procedures you are requesting. Include evidence of your ability to perform the procedures as listed in the delineated privilege requirements. DEPARTMENT CHAIRMAN: For each requested privilege, check if the physician has provided sufficient evidence of competence to perform the requested privilege in accordance with the delineated privilege requirements. CREDENTIALS COMMITTEE: For each requested privilege, check if granted or denied. Explain the reason(s) for each denied privilege. ********************************************************************************************************* The following privileges are considered to be CORE S for the Department of Emergency Medicine: AIRWAY TECHNIQUES: Endotracheal intubation, nasal; Neuromuscular blockade; Percutaneous transtracheal ventilation; Oropharyngeal airways and Oxygen therapy ANESTHESIA: Local anesthesia and Rapid sequence induction CARDIAC PROCEDURES: Cardiac pacing, transthoracic; Cardiac pacing, transvenous; Cardioversion defibrillation; Emergency Drug Therapy and Pediatric resuscitation DIAGNOSTIC PROCEDURES: IVP, contrast; Proctoscopy; Tonometry and Slit lamp exam GENITOURINARY TECHNIQUES: Bladder catheterization (foley) and Culdocentesis HEAD & NECK: Epistaxis control HEMODYNAMIC TECHNIQUES: Central venous access, subclavian; Arterial blood gases/interpretation; Peripheral venous access and Blood administration ORTHOPEDIC PROCEURES: Fracture/dislocation; Immobilization/traction; Cervical traction technique and Trephination nail THORACIC PROCEDURES: Tube thoracostomy and Pericardiocentesis OTHER TECHNIQUES: Foreign body removal; Gastric lavage; Incision & drainage; Electrocautery; Interpretation of laboratory tests and Emergency C-Section after death of mother. *********************************************************************************************************** CREDENTIALS COMMITTEE AIRWAY TECHNIQUES Cricothyrotomy Endotracheal intubation Manual/mechanical ventilation
PAGE 2 ANESTHESIA Regional nerve blocks Conscious sedation CARDIAC PROCEDURES Cardiac massage, closed/open Cardiac pacing Cardiopulmonary resuscitation/acls Adult/Peds Cardiography - EKG/Rhythm strip DIAGNOSTIC PROCEDURES Arthrocentesis Cystourethrogram Lumbar puncture Nasogastric/oral gastric tube Pericardiocentesis Peritoneal lavage Thoracentesis GENITOURINARY TECHNIQUES Suprapubic catheterization Precipitous delivery of newborn HEAD/NECK Laryngoscopy direct/indirect Naso/pharyngeal endoscopy
PAGE 3 Emergency craniotomy (subdural tap) HEMODYNAMIC TECHNIQUES Central venous access Peripheral venous access (venous cutdown) Intraosseus infusion Arterial cannulation Auto transfusion ORTHOPEDIC PROCEDURES Closed reduction - Emergent Cervical immobilization Bursa or joint injection THORACIC PROCEDURES Thoracostomy Emergency thoracotomy Intracardiac injection OTHER TECHNIQUES Wound management/suture techniques Hernia reduction Use of water sealed drainage techniques Anoscopy Complete history & physical exam OMT
PAGE 4 Ultrasound OTHER PROCEDURES (LIST) COMMENTS: of Applicant Chairman, Department of Emergency Medicine of Review Chairman, Credentials Committee of Review
PAGE 5 ****************************************************************************** THIS SECTION IS USED FOR ONLY THOSE REAPPOINTMENT CYCLES LISTED BELOW I agree to the same privileges as listed above for the following reappointment cycle. 2008-2009 Cycle 2010-2011 Cycle 2012-2013 Cycle 6/24/10