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Emergency Medicine Privilege Form

This document is an application form for clinical privileges in Emergency Medicine at a hospital. It outlines the privileges requested by the applicant, including the assessment and treatment of patients, various diagnostic and procedural capabilities, and the responsibilities of the applicant regarding their qualifications. The form also includes sections for recommendations and approvals from the Medical Staff and Board of Directors.

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Michael Sid
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27 views

Emergency Medicine Privilege Form

This document is an application form for clinical privileges in Emergency Medicine at a hospital. It outlines the privileges requested by the applicant, including the assessment and treatment of patients, various diagnostic and procedural capabilities, and the responsibilities of the applicant regarding their qualifications. The form also includes sections for recommendations and approvals from the Medical Staff and Board of Directors.

Uploaded by

Michael Sid
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Hospital Logo

Hospital Name
Hospital Address

Application for Clinical Privileges – Emergency Medicine

Applicant Name: _____________________________________________________

Staff Category: _______________________________________ Specialty: ______________________________________

Effective from _______/_______/_______ to _______/_______/_______

Request all privileges desired by checking the applicable requested box.


Request Not Requested Granted Not Granted
Assess, evaluate, diagnose, and initially treat patients of all ages who
present in the ED with any symptom, illness, injury, or condition. Provide
immediate recognition, evaluation, care, stabilization, and disposition in
response to acute illness and injury. Privileges include the performance of
history and physical examinations, the ordering and interpretation of
diagnostic studies, including laboratory, diagnostic imaging, and
electrocardiographic examinations, and the administration of medications
normally considered part of the practice of emergency medicine.. The core
privileges in this specialty include the procedures on the attached
procedures list and such other procedures that are extensions of the same
techniques and skills.
Admit to the appropriate level of care
Procedures: Remove those procedures not within
capabilities and capacities of Hospital
Diagnostic procedures including arthrocentesis, lumbar puncture, slit lamp
examination, tonometry, pulse oximetry, arterial blood gas sampling and
analysis; EKG, and preliminary X-ray interpretation
Techniques utilized to stabilize the airway including the use of airways and
rapid sequence intubation, image guided and video assisted laryngoscopy
and use of paralytic agents
Cricothyrotomy and tracheotomy
Mechanical ventilation - temporary
Skeletal procedures including stabilization of fractures and dislocations;
immobilization techniques; reduction techniques; backboard and cervical
immobilization techniques
Excision of thrombosed hemorrhoids
Foreign body removal
Gastric lavage
Jejunostomy and gastrostomy tube replacement
Wound management and closure including management of burns, nail
removal, I & D abscess and evacuation of hematoma
Emergent delivery of newborns; Doppler fetal heart tones; pelvic exam;
perimortum C-Section; and removal of IUD
Thoracentesis, thoracostomy, pericardiocentesis and emergent

1
Applicant Name: _____________________________________________________

Staff Category: _______________________________________ Specialty: ______________________________________

Effective from _______/_______/_______ to _______/_______/_______

thoracotomy
Paracentesis and lavage
Suprapubic tap and catheterization
Vascular access including arterial catheter insertion; central venous
access, venous cutdown and pulmonary artery catheter insertion
Use of external pacemaker and elective cardioversion
Administration of local anesthetics including basic and regional blocks
Perform and interpret emergent, focused and investigational ultrasound

Endoscopy: Diagnostic Endoscopy includes biopsy and


polypectomy as applicable. Remove those procedures
not within capabilities and capacities of Hospital
Anoscopy
Proctoscopy
Sigmoidoscopy
Colonoscopy
EGD without dilation
EGD for removal of foreign body
EGD for dilation of stricture
Moderate Sedation: Remove this privilege not within
capabilities and capacities of Hospital
Moderate/Conscious Sedation
Other Privileges Desired (Not Listed Above)

Signature of Applicant:

2
Applicant Name: _____________________________________________________

Staff Category: _______________________________________ Specialty: ______________________________________

Effective from _______/_______/_______ to _______/_______/_______

I have requested only those privileges for which by education, training, current experience, and demonstrated competency I
am entitled to perform and that I wish to exercise at (Insert Name of Hospital).

I also understand that by making this request I am bound by the applicable Medical Staff Bylaws and/or policies of (Insert
Name of Hospital). I also attest that my professional liability insurance covers the privileges I have requested.

I understand that it is my responsibility to provide (Insert Name of Hospital) with documentation of my education, training,
current experience and information regarding the number of services and procedures I have performed in order to assist the
Medical Staff in the determination of competency or continued competency.

I affirm that I will obtain a consultation with a qualified medical staff member when it is in the best interest of the patient
and/or when my expertise does not meet the clinical needs of the patient.

Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions
are governed by the applicable section of the Medical Staff Bylaws and related documents.

________________________________________________________ _______________________________
Signature of Applicant Date

Medical Staff/Credentials Committee Recommendations – Privileges


I/we have reviewed the requested clinical privileges and supporting documentation and make the following
recommendation(s): Please check the applicable box(es)

Recommend all requested privileges


Do not recommend any of the requested privileges
Recommend privileges with the following conditions/modifications/deletions (listed below)

Privilege Conditions/Modification/Deletion/Explanation

________________________________________________ ________________________________________
Medical Staff/Credentials Committee Date

Board of Directors Determination

3
Applicant Name: _____________________________________________________

Staff Category: _______________________________________ Specialty: ______________________________________

Effective from _______/_______/_______ to _______/_______/_______

I/we have reviewed the requested clinical privileges and supporting documentation and make the following determination(s):
Please check the applicable box(es).

Approve all requested privileges


Approve none of the requested privileges
Approve the following privileges with the following conditions/modifications/deletions (listed below)

Privilege Conditions/Modification/Deletion/Explanation

_______________________________________________ ________________________________________
Board of Directors Date
Hospital Name

Form Approved By:

Medical Staff: _______________________


Date

Board of Directors: ____________________


Date

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