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    Ms-001 (2) Clinical Priv Form Emergency 2019

    Uploaded by

    Athira Rajan
    This document is an application for clinical privileges in the emergency department of Bader al-Janoub General Hospital in Najran, Saudi Arabia. It lists the applicant's information and certifications. It then lists various clinical procedures and asks the applicant to request privileges and the hospital to grant, grant with supervision, or deny each privilege. Privileges include treating emergency patients, ordering tests and consultations, suturing wounds, resuscitation, and transfusions. The application must be recommended by the emergency department head and approved by the medical director and hospital director.

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    © All Rights Reserved
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    Ms-001 (2) Clinical Priv Form Emergency 2019

    Uploaded by

    Athira Rajan
    277 views3 pages
    This document is an application for clinical privileges in the emergency department of Bader al-Janoub General Hospital in Najran, Saudi Arabia. It lists the applicant's information and certifications. It then lists various clinical procedures and asks the applicant to request privileges and the hospital to grant, grant with supervision, or deny each privilege. Privileges include treating emergency patients, ordering tests and consultations, suturing wounds, resuscitation, and transfusions. The application must be recommended by the emergency department head and approved by the medical director and hospital director.

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    4. Ms-001 (2) Clinical Priv Form Emergency 2019

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    This document is an application for clinical privileges in the emergency department of Bader al-Janoub General Hospital in Najran, Saudi Arabia. It lists the applicant's information and certifications. It then lists various clinical procedures and asks the applicant to request privileges and the hospital to grant, grant with supervision, or deny each privilege. Privileges include treating emergency patients, ordering tests and consultations, suturing wounds, resuscitation, and transfusions. The application must be recommended by the emergency department head and approved by the medical director and hospital director.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    277 views3 pages

    Ms-001 (2) Clinical Priv Form Emergency 2019

    Uploaded by

    Athira Rajan
    This document is an application for clinical privileges in the emergency department of Bader al-Janoub General Hospital in Najran, Saudi Arabia. It lists the applicant's information and certifications. It then lists various clinical procedures and asks the applicant to request privileges and the hospital to grant, grant with supervision, or deny each privilege. Privileges include treating emergency patients, ordering tests and consultations, suturing wounds, resuscitation, and transfusions. The application must be recommended by the emergency department head and approved by the medical director and hospital director.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    Kingdom of Saudi Arabia

    ‫المملكة العربية السعودية‬


    MINISTRY OF HEALTH General
    ‫وزارة الصحة‬
    Directorate For Health Affairs Of Najran
    ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
    Region
    ‫مستشفى بدر الجنوب العام‬
    Bader al-Janoub General Hospital

    APPLICATION FOR CLINICAL PRIVILEGES IN


    THE EMERGENCY DEPARTMENT
    NAME: EMPLOYEE NUMBER:
    ID NUMBER: YEARS OF EXPERIENCE:
    SAUDI COUNCIL REGISTRATION #: DATE OF EXPIRATION:

    Designation:

     RESIDENT  SPECIALIST  CONSULTANT

    Certification/s:
     BCLS  ACLS  ATLS  PALS  Other/s (please specify)________________

    Clinical Privilege Category:


     TEMPORARY  APPROVED  EMERGENCY
    At the time of a life-threatening clinical emergency, any Practitioner may render whatever care he/she believes to be
    indicated regardless of the extent of his/her granted privileges.

    Instructions:
    APPLICANT: In the first column below, place a check in the appropriate box whether you have requested for the privileges
    listed on the second column.
    GENERAL INSTRUCTION: Please tick () in the appropriate column whether the privileges that the applicant applied for
    is “GRANTED”, “GRANTED WITH SUPERVISION” or “DENIED”. (If the requested privileges are either
    “GRANTED WITH SUPERVISION” or “DENIED”, the “REMARKS” column may be necessary to be filled up).
    Note: A copy of this privilege list will be given to the applicant. The original privilege list will be kept in the “Personnel
    File”. The Clinical Privilege of Medical Staffs will be reviewed every 2 years along with their Annual Evaluation for Contract
    Renewal or as necessary. (For New Medical Staffs, review of privilege will be after 90 days from the start of employment.)

    REQUESTED GRANTED
    CLINICAL
    PROCEDURES
    GRANTED WITH DENIED REMARKS
    YES NO SUPERVISION
    GENERAL (BASIC) PROCEDURES
      Admitting Privileges   
    Conscious IV Sedation
      (May require Anesthesia   
    approval)
    CORE PRIVILEGES
      Treat, perform history and   
    physical exam, and provide
    MS-001 (2) Page 1 of 3
    Kingdom of Saudi Arabia
    ‫المملكة العربية السعودية‬
    MINISTRY OF HEALTH General
    ‫وزارة الصحة‬
    Directorate For Health Affairs Of Najran
    ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
    Region
    ‫مستشفى بدر الجنوب العام‬
    Bader al-Janoub General Hospital

    APPLICATION FOR CLINICAL PRIVILEGES IN


    THE EMERGENCY DEPARTMENT
    care to patients presenting
    in emergency department
    Order diagnostic/therapeutic
      services limited to ER   
    protocols
      Request consultation   
    Management of problems in
        
    pain relief
    Suturing of uncomplicated
        
    superficial wounds

    REQUESTED GRANTED
    CLINICAL
    PROCEDURES
    GRANTED
    WITH DENIED REMARKS
    YES NO SUPERVISION
    RENDER ANY CARE IN LIFE THREATENING EMERGENCY
      Cardiopulmonary resuscitation   
    Naso Gastric Tube & Urinary
        
    Catheter insertion
    Simple Cast Application for
      Non Fractured Cases (For   
    immobilization purposes)
    ORDERING BLOOD TRANSFUSION AND INFUSION
    Infusion (IV Fluids, plasma,
        
    etc.)
      Intravenous medicines   
    Transfusion of blood and
        
    blood products

    If at any stage you wish to perform any surgical or therapeutic procedure that is not listed in this application, you must refer
    to the Credentialing and Privileging Committee.

    CLINICAL PRIVILEGES APPROVAL


    STAMP &
    NAME & DESIGNATION DATE
    SIGNATURE
    Requested by:

    ___________________________

    MS-001 (2) Page 2 of 3


    Kingdom of Saudi Arabia
    ‫المملكة العربية السعودية‬
    MINISTRY OF HEALTH General
    ‫وزارة الصحة‬
    Directorate For Health Affairs Of Najran
    ‫المديرية العامة للشئون الصحية بمنطقة نجران‬
    Region
    ‫مستشفى بدر الجنوب العام‬
    Bader al-Janoub General Hospital

    APPLICATION FOR CLINICAL PRIVILEGES IN


    THE EMERGENCY DEPARTMENT

    Dr. AMMAR KABBASHI


    Recommended by:
    Head of Emergency Department

    Dr. Musaab Salih


    Medical Director/
    Medical Credentialing & Privileging
    Approved by: Committee Chairman

    Mr. Ibrahim Hamad Mana Al Amer


    Hospital Director

    MS-001 (2) Page 3 of 3

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