UNIVERSITY HOSPITAL



UNIVERSITY HOSPITAL

RADIOLOGY NURSE PRACTITIONER

REQUEST FOR PRIVILEGES

To be eligible to request clinical privileges, the following threshold criteria must be met.

EDUCATION: RN and NP

TRAINING:

Registered professional nurse who has successfully completed/graduated from an accredited nurse

practitioner educational program, is currently certified by the AANP, PNCB, NCC or ONCC, and

is authorized to practice by the Georgia Board of Nursing. Applicant must meet the requirements

outlined in Allied Health Professional Policy and Procedure MS-1.

EXPERIENCE:

Current demonstrated competence and an adequate level of current experience documenting the ability to

provide services at an acceptable level of quality and efficiency. All initial applicants at completion of

training must provide a letter of recommendation assessing performance from the Training Director.

All initial applicants beyond 12 months of training completion must provide a letter of recommendation

assessing performance from the hospital’s Chief of Staff, Department Chair, or Supervising Physician.

The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E.

CORE PRIVILEGES: Functions under the supervision and general direction of his/her sponsoring physician.

Nurse Practitioners are permitted by the state law to perform delegated medical acts consistent with

protocols established with the sponsoring physician(s).

(This list is a sampling of privileges included in the core but is not intended to be an all-encompassing list

but rather reflective of the categories/types of privileges included in the core.)

REQUESTED GRANTED

|Complete history and physical examination to be reviewed, approved and co-signed by the supervising physician. | | |

|Document a clinical resume with the approving signature of the supervising physician. | | |

|Assist with patient clinical rounds of supervising physician’s patients & initiate approved | | |

|clinical activity. | | |

|Enter assessment of patient progress in the progress notes of the medical record to be | | |

|reviewed, approved and signed by the supervising physician. | | |

|Assist the physician in the review, collection & interpretation of clinical, diagnostic data | | |

|reports. Established physician protocols are to be utilized in subsequent prescriptions for | | |

|diagnostic studies. | | |

|Perform non-invasive clinical procedures and treatments consistent with supervising | | |

|physician’s protocols. | | |

|Participate in and institute patient education & discharge planning process. | | |

|Dictate discharge summaries in preparation for supervising physician’s review, approval | | |

|& signature. | | |

|Initiate physician prescription for medical treatment after discussion with and approval by | | |

|the supervising physician for such treatment. | | |

|Dictate operative summaries only when personally performing the procedure and | | |

|countersigned by the sponsoring physician. | | |

Applicants requesting any other special privileges listed below must present documentation of training in

each privilege requested with a letter from the training director attesting to the applicant’s competence

and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff

and the Governing Board of University Hospital.

RADIOLOGY NURSE PRACTITIONER

REQUEST FOR PRIVILEGES

PAGE 2

SPECIAL PRIVILEGES to include: REQUESTED GRANTED

|Feeding Tube Placement (One month shadowing with radiologist to be followed by the performance of a minimum of| | |

|25 procedures with the radiologist) | | |

|PICC Line Placement (One month shadowing with radiologist to be followed by the performance of a minimum of 25| | |

|procedures with the radiologist) | | |

|Routine drainage procedures including paracentesis without biopsy (One month shadowing with radiologist to be | | |

|followed by the performance of a minimum of 15 procedures with the radiologist) | | |

|Port-o-cath Placement (One month shadowing with radiologist to be followed by the performance of a minimum of | | |

|25 procedures with the radiologist) | | |

|Peg tube replacement and exchange (One month shadowing with radiologist to be followed by the performance of a| | |

|minimum of 15 procedures with the radiologist) | | |

|Tunneled and Non-tunneled central line placement and revision to include fibrin sheath disruption with | | |

|associated venogram. This would include central lines, permanent and temporary hemodialysis catheters. (One | | |

|month shadowing with radiologist to be followed by the performance of a minimum of 25 procedures with the | | |

|radiologist) | | |

|Ultrasound guided thoracentesis. (One month shadowing with radiologist to be followed by the performance of a | | |

|minimum of 15 procedures with the radiologist) | | |

|Removal of Nephrostomy tube with fluoro guidance. (One month shadowing with radiologist to be followed by the | | |

|performance of a minimum of 10 procedures with the radiologist) | | |

|The applicant is required to submit a separate letter of | | |

|request for any privilege not included on this form. | | |

_____________________________ ______________ ________________________________

Applicant’s Signature Date Applicant’s Printed Name

I hereby recommend that the above applicant be allowed to perform the duties and/or responsibilities listed above as a Nurse Practitioner under supervision at University Hospital. I shall assume full responsibility for this individual’s actions. (If the Nurse Practitioner will work for more than one practitioner in a group, each practitioner must sign and date.) I also agree to abide by the Medical Staff’s Policy and Procedure regarding completion of competency evaluations as requested by the Medical Staff Office for any Allied Health Practitioner.

___________________________________ _______________ ________________________________

Supervising Physician’s Signature Date Physician’s Printed Name

___________________________________ _______________ ________________________________

Supervising Physician’s Signature Date Physician’s Printed Name

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download