Orthopedic Surgery Clinical Privileges
( Initial ( change in practice prerogatives ( renewal of practice prerogatives
To be eligible to request these clinical practice prerogatives, the applicant must meet the following threshold criteria:
|Definition: |An Advance Practice Nurse is defined by the Texas Board of Nursing (TBON Rules and Regulations Section 219.2 Definition) as |
| |“A registered nurse authorized by the Board to practice as an advanced practice nurse based on completing an advanced |
| |practice nursing educational program acceptable to the Board. The term includes a nurse practitioner, nurse-midwife, nurse |
| |anesthetist, and a clinical nurse specialist. The advanced practice nurse is prepared to practice in an expanded role to |
| |provide health care to individuals, families, and/or groups in a variety of settings including, but not limited to homes, |
| |hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice. |
| |The advanced practice nurse acts independently and/or in collaboration with other health care professionals in the delivery |
| |of health care services.” |
|Basic Education: |Graduate from a post basic advanced practice nurse program at the certificate or master’s degree level (eg MSN or MS). |
|Minimal Formal Training: |In addition to being an RN, the applicant must demonstrate successful completion of an Nurse Practitioner master’s degree |
| |nursing accredited program from an accredited institution in the applicant’s specialty area or must demonstrate successful |
| |completion a formal postgraduate Nurse Practitioner track or program (within the applicant’s specialty area) within an |
| |accredited school of nursing program granting graduate-level academic credit (e.g., graduate, nonmatriculating program). The|
| |Nurse Practitioner has attended a post basic advanced practice nurse program at the certificate or master’s degree level. |
| |(TBON Rules and Regulations, Section 219.1 Accredited Program - A program that has been determined to have met the standards|
| |set by a national advanced practice nursing education accrediting body recognized by the Board). |
|Licensure: |Current unrestricted licensure as an Advance Practice Nurse by the Texas State Board of Nurse Examiners and approved for |
| |advanced practice. |
|Certification: |Successfully completion of certified nurse practitioner program in requested specialty area and board certification by the |
| |National Commission on American Academy of Nurse Practitioners (AANP) or American Nurses Credentialing Center (ANCC). |
|Malpractice Insurance: |Proof of malpractice insurance in the amounts of $200,000/$600,000 as a minimum with applicant’s name listed as the insured.|
|General Scope of |May provide only those services for which he/she is specifically authorized according to this scope of practice. |
|Services/Functions: | |
|Categories of Patients |Only patients of the documented and approved Supervising Physician(s). |
|Practitioner may Treat: | |
|Competency Requirements: |Initial Applicant: Each initial applicant shall submit documentation (either from their training program or from an |
| |accredited institution) of at least 24 cases demonstrating the provision of inpatient services in the last 24 months. If |
| |applicant is unable to provide documentation of 24 cases in the last 24 months, the Chief of Medicine will assign an |
| |additional level of focused review appropriate for the practice prerogatives requested to ensure current clinical |
| |competence. Applicants have the burden of producing information deemed adequate by the hospital for a proper evaluation of |
| |current competence, and other qualifications and for resolving any doubts. |
| |Reappointment: Each practitioner must be able to provide documentation of at least 24 cases, from an accredited institution,|
| |demonstrating the provision of inpatient services in the last 24 months. If the practitioner has not performed the |
| |sufficient number of cases at this hospital, he/she will be requested to provide appropriate documentation from another |
| |accredited institution to demonstrate his/her current clinical competence. If an applicant is unable to provide |
| |documentation of 24 cases in the last 24 months, the Chief of Medicine will assign an additional level of focused review |
| |appropriate for the practice prerogatives requested to ensure current clinical competence. |
|Life Safety Certifications: |None |
|Prescriptive Authority: |An approved BNE number for prescriptive authority must be issued for prescriptive authorization. Pre-signed prescriptions by|
| |the supervising physician may be carried out according to the protocols that authorize diagnosis of the patient’s condition |
| |and treatment. |
|Clinical References: |Initial Applicant: Training Director from the applicant’s training program (if completed program within past 5 years) or |
| |Chief of Medicine from the primary hospital where applicant has been affiliated within the past year and two additional peer|
| |references who have recently worked with the applicant and directly observed his/her professional performance over a |
| |reasonable period of time and who will provide reliable information regarding current clinical competence, ethical character|
| |and ability to work with others. |
| |Reappointment: A letter of reference from the Chairman of the applicant’s primary practicing facility or a peer reference, |
| |preferably from CMC current medical staff, who has recently worked with the applicant and directly observed his/her |
| |professional performance over a reasonable period of time and who will provide reliable information regarding current |
| |clinical competence, ethical character, health status and ability to work with others. |
|Medical Record Responsibility: |Clearly, legibly, completely and in a timely fashion describe each service he or she provides to a patient in the hospital |
| |and relevant observation. Standard rules regarding authentication of, necessary content of, and required time frames for |
| |preparing and completing the medical record and portions thereof are applicable to all entries made with facility |
| |documentation requirements. All documentation in the medical record must be co-signed by the supervising physician. |
|Supervising Physician |Degree of Supervision: A physician on the medical staff shall recommend an individual applying for practice prerogatives. |
|Requirement: |The applicant shall participate in the management and care of patients under the general supervision or direction of the |
| |Supervising Physician. Supervising Physician is a member in good standing of the Centennial Medical Center medical staff and|
| |currently licensed and in good standing by the Texas Medical Board. Must have continuous supervision (by telecommunications |
| |or in person) by the supervising / sponsoring physician. |
|Professional Practice Evaluation:|Initial Applicant: A period of focused professional practice evaluation (may include chart review, monitoring clinical |
| |practice patterns, proctoring, external peer review, and discussions with other individuals involved in the care of patient)|
| |will be followed as outlined in the Focus Professional Practice Evaluation (FPPE) policy. Reappointment: A period of |
| |ongoing professional practice evaluation (may include chart review, monitoring clinical practice patterns, proctoring, |
| |external peer review, and discussions with other individuals involved in the care of patient) will be followed as outlined |
| |in the Ongoing Professional Practice Evaluation (OPPE) review policy. |
|Reappointment Requirement: |Reappointment shall be based on unbiased, objective results of care according to documentation of clinical activity within |
| |the scope of practice prerogatives requested. Applicants must be able to demonstrate that they have maintained competence |
| |by showing evidence that they have provided an adequate volume of tests or procedures commensurate with the subspecialty for|
| |which practice prerogatives are requested over the reappointment cycle. In addition, continuing medical education related |
| |to these practice prerogatives may be required. |
If you meet the threshold criteria above, you may apply for those practice prerogatives appropriate to your training and current competence. Any practitioners who hold the following practice prerogatives prior to the revision date are grandfathered for those practice prerogatives; however, all practitioners must meet any new criteria defined for maintaining practice prerogatives at reappointment.
Applicant: Place a check in the (R) column for each practice prerogative requested. All applicants must provide documentation of the number of hospital cases treated during the past 24 months.
|(R) |(A) |GENERAL PRACTICE PREROGATIVES |Supporting |FPPE |Reappt Criteria |
| | | |documentation of |See below plus |If no cases or |
| | | |number of patients |additional |insufficient cases, |
| | | |or procedures |cases at |additional proctoring |
| | | |performed in the |discretion of |may be required, may |
| | | |past 24 months, |proctor |include privilege |
| | | |preferably at CMC | |specific CME |
|( |( |Nurse Practitioner Core Practice prerogatives | |Review of 3 |Current demonstrated |
|#R1# |#G1# |Patient management |________ |representative |competence and provision|
| | |➤ Perform history and physical exam | |cases. |of care for |
| | |➤ Administer medications and perform other emergency treatment | | |approximately 24 |
| | |➤ Assess for levels of comfort (e.g., pain, palliative care, end of life, bad news)| | |inpatients and/or |
| | |and initiate appropriate interventions | | |outpatients in past 2 |
| | |➤ Complete EMTALA-specified medical screening examination (MSE) | | |years. |
| | |➤ Counsel and instruct patients, families, and caregivers as appropriate | | | |
| | |➤ Direct care as specified by medical staff–approved protocols | | | |
| | |➤ Initiate appropriate referrals | | | |
| | |➤ Order and initial interpretation of diagnostic testing and therapeutic | | | |
| | |modalities, such as laboratory tests, medications, hemodynamic monitoring, | | | |
| | |treatments, x-ray, EKG, IV fluids and electrolytes, etc. | | | |
| | |➤ Perform sexual assault examination | | | |
| | |➤ Record progress notes | | | |
| | |➤ Specifically assess and initiate appropriate interventions for violence, neglect,| | | |
| | |and abuse (e.g., physical, psychological, sexual, substance) | | | |
| | |➤ Specifically assess and initiate appropriate interventions and disposition for | | | |
| | |suicide risk | | | |
| | |➤ Triage patients’ health needs/problems | | | |
| | |➤ Dictate discharge summaries | | | |
| | | | | | |
| | |Anesthesia | | | |
| | |➤ Inject local anesthetics | | | |
| | |➤ Perform regional nerve block and digital nerve block | | | |
| | | | | | |
| | |Diagnostic procedures | | | |
| | |➤ Anoscopy | | | |
| | |➤ Arthrocentesis (e.g., knee, elbow) | | | |
| | |➤ Compartment pressure measurement | | | |
| | |➤ Insert and remove nasogastric tube | | | |
| | |➤ Perform slit-lamp examination | | | |
| | |➤ Tonometry | | | |
| | | | | | |
| | |Genital/urinary | | | |
| | |➤ Perform urinary bladder catheterization (e.g., Foley, suprapubic) | | | |
| | | | | | |
| | |Head and neck | | | |
| | |➤ Control of epistaxis | | | |
| | |➤ Removal of rust ring | | | |
| | | | | | |
| | |Resuscitation | | | |
| | |➤ Cardiopulmonary resuscitation | | | |
| | |➤ Neonatal resuscitation | | | |
| | | | | | |
| | |Hemodynamic techniques | | | |
| | |➤ Insert and remove arterial catheters | | | |
| | |➤ Insert and remove central venous catheters | | | |
| | |➤ Intraosseous infusion | | | |
| | |➤ Peripheral venous cutdown | | | |
| | | | | | |
| | |Skin and wound care management | | | |
| | |➤ Apply, remove, and change dressings and bandages | | | |
| | |➤ Debridement, suture, and general care for superficial wounds and minor | | | |
| | |superficial surgical procedures | | | |
| | |➤ Laceration repair—simple, intermediate, complex | | | |
| | | | | | |
| | |Obstetrics | | | |
| | |➤ Assist with imminent childbirth and postdelivery maternal care | | | |
| | | | | | |
| | |Other techniques | | | |
| | |➤ Arterial puncture and blood gas sampling | | | |
| | |➤ Perform excision of thrombosed hemorrhoids | | | |
| | |➤ Remove foreign bodies (ears, nose, rectum, soft tissue, throat, vaginal) | | | |
| | |➤ Replace gastrostomy tube | | | |
| | |➤ Incision and drainage of abscess | | | |
| | |➤ Insert Heimlich (small gauge) valve | | | |
| | |➤ Perform ear, nose, rectum, soft tissue, throat, vaginal, and gastric lavage | | | |
| | |➤ Perform venous punctures for blood sampling, cultures, and IV catheterization | | | |
| | |➤ Trephination of nails and removal of nails | | | |
| | |Skeletal procedures | | | |
| | |➤ Fracture/dislocation immobilization techniques (e.g., casting, splinting) | | | |
| | |➤ Fracture/dislocation reduction techniques | | | |
| | |➤ Spine immobilization techniques | | | |
|( |( |Prescriptive Authority | | | |
|#R2# |#G2# |Write prescriptions per schedule, Schedule is : ____________(eg. III-V) | | | |
| | | | | | |
| | |Criteria/No. of Procedures: | | | |
| | |Must have current and unrestricted DEA and DPS | | | |
|( |( |Prescriptive Authority | | | |
|#R3# |#G3# |Verbal prescriptive orders, Schedule is : ____________(eg. III-V) | | | |
| | | | | | |
| | |Criteria/No. of Procedures: | | | |
| | |Must have current and unrestricted DEA and DPS | | | |
|( |( |REMOVAL FROM GENERAL PRACTICE PREROGATIVES: Should applicant’s current practice | | | |
|#R4# |#G4# |limitations or current competence exclude performance of any practice prerogatives | | | |
| | |specified in the list of core practice prerogatives, please indicate here. | | | |
| | |Applicant and/or MEC must document reasons for exclusion. | | | |
| | |___________________________________________________________ | | | |
| | |___________________________________________________________ | | | |
| | |SPECIAL PROCEDURES/TECHNIQUES - If desired, noncore practice prerogatives are | | | |
| | |requested individually, in addition to requesting the core. To be eligible to apply| | | |
| | |for a special procedure listed below, the applicant must demonstrate successful | | | |
| | |completion of an approved, recognized course when such exists, or acceptable | | | |
| | |supervised training in residency, fellowship or other acceptable experience, and | | | |
| | |provide documentation of competence, case logs, in performing that procedure | | | |
| | |consistent with the criteria set forth in medical staff policies governing the | | | |
| | |exercise of specific practice prerogatives. | | | |
|( |( |Exercise Testing | |First 3 cases |Demonstrated current |
|#R5# |#G5# | |________ |to be reviewed,|demonstrated competence |
| | |Criteria/No. of Procedures | |and proctored, |and evidence of the |
| | |As indicated in the American College of Physicians/ACC/AHA task force statement on | |if applicable. |performance of at least |
| | |clinical competence in exercise testing, exercise testing in select patients can be| | |10 cases in past 24 |
| | |performed safely by an appropriately trained nurse/mid level practitioner under the| | |months. |
| | |supervision of a physician, who should be in the immediate vicinity (on campus) and| | | |
| | |available for emergencies. Must be ACLS trained and certified and demonstrate | | | |
| | |supervision of at least 100 stress tests, with substantiating documentation with | | | |
| | |review and recommendation from Chairman of Cardiology and Centennial | | | |
| | |Administration. | | | |
| | |ADDITIONAL PRACTICE PREROGATIVES: A request for any additional practice | | | |
| | |prerogatives not included on this form must be submitted to the Medical Staff | | | |
| | |Office and will be forwarded to the appropriate review committee to determine the | | | |
| | |need for development of specific criteria, personnel and equipment requirements. | | | |
| | |EMERGENCY: In the case of an emergency, any individual who has been granted | | | |
| | |clinical practice prerogatives is permitted to do everything possible within the | | | |
| | |scope of license, to save a patient’s life or to save a patient from serious harm, | | | |
| | |regardless of staff status or practice prerogatives granted. | | | |
Recommending Individual/Committee must note: (A) = Recommend Approval as Requested. NOTE: If conditions or modifications are noted, the specific condition and reason for same must be stated below.
Acknowledgement of APPLICANT
I certify that I meet the minimum threshold criteria to request the above practice prerogatives and have provided documentation to support my eligibility to request each group of procedures requested. I have requested only those practice prerogatives for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise at Centennial Medical Center, and I understand that:
(a) in exercising any clinical practice prerogatives granted, I am constrained by hospital and medical staff bylaws, rules & regulations, policies and rules applicable generally and any applicable to the particular situation
(b) any restriction on the clinical practice prerogatives 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 or related documents
Signed:___________________________________________________ Date: ___________________
ACKNOWLEDGEMENT OF SUPERVISING PHYSICIAN
As Supervising Physician, I shall be a member in good standing of the Centennial Medical Center medical staff, maintain a current licensed and in good standing by the Texas Medical Board. The Supervising Physician must:
- Assume responsibility for supervision or monitoring the Allied Health Professional’s practice as stated in the appropriate hospital or medical staff policy governing Allied Health Professionals,
- Be available or provide an alternate to provide consultation when requested and to intervene when necessary and
- Assume responsibility for the care of any patient when requested by the Allied Health Professional or required by this policy or in the interest of patient care.
_____________________________ _____________________________ _____/_____/_____
Supervising Physician’s Name – Print Signature Date
_____________________________ _____________________________ _____/_____/_____
Supervising Physician’s Name – Print Signature Date
Department Chair’s Recommendation
I certify that I have reviewed and evaluated this individual’s request for practice prerogatives, the verified credentials, quality data and/or other supporting information. Based on the information available and/or personal knowledge, I recommend the following:
Department Chair Signature: ______________________________________________ Date: _______________________
( Recommend practice prerogatives as requested
( Do not recommend the requested practice prerogatives due to: _________________________________
( Recommend requested practice prerogatives with the following conditions/modifications: ___________________________________________
Credentials Committee Review/Recommendation Action Date: _______________________________________
( Recommend practice prerogatives as requested
( Do not recommend the requested practice prerogatives due to: _________________________________
( Recommend requested practice prerogatives with the following conditions/modifications: ____________________________________________
Medical Executive Committee Review/Recommendation Date: ________________________________________
( Recommend practice prerogatives as requested
( Do not recommend the requested practice prerogatives due to: ________________________________
( Recommend requested practice prerogatives with the following conditions/modifications: _____________________________________________
Governing Board Decision Date: __________________________________________________________
( Recommend practice prerogatives as requested
( Do not recommend the requested practice prerogatives due to: ________________________________
( Recommend requested practice prerogatives with the following conditions/modifications: _____________________________________________
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