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Nursing Clinical Privileges Department: ICU /NICU /LR

This document contains a nursing clinical privileges request form listing various clinical procedures and tasks. The applicant is asked to check "yes" or "no" for each requested privilege. The chairperson will then initial whether the privilege is granted, granted with supervision, or denied. The bottom of the form contains spaces for the applicant's signature certifying their health, the nursing superintendent's recommendation, and the credentialing committee chair's approval.

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KUMARJIT SAHA
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23K views3 pages

Nursing Clinical Privileges Department: ICU /NICU /LR

This document contains a nursing clinical privileges request form listing various clinical procedures and tasks. The applicant is asked to check "yes" or "no" for each requested privilege. The chairperson will then initial whether the privilege is granted, granted with supervision, or denied. The bottom of the form contains spaces for the applicant's signature certifying their health, the nursing superintendent's recommendation, and the credentialing committee chair's approval.

Uploaded by

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

Nursing Clinical Privileges

Department : ICU /NICU /LR Photograph

Name: Date:

Applicant: In the first columns below, place a check in the appropriate box for each privilege listed below.
A yes or no response must be entered for every item.
Chairperson: Place your initials in the appropriate column. An entry must be made for every item.

Granted
Yes No Clinical Privilege Requested Granted with Denied
Supervision

  Vital Parameter
  Bed Making
  Patient hygiene
  Sample collection

  Drug Administration(Oral ,I/V,I/M,S/C)


  Ryle’s tube feeding
  Catheterization
  Enema
  Major Dressing
  Care of pressure area /Personal hygiene

  Oxygen administration

  Administration of high risk medication

  Steam inhalation

  Nebulization

  ECG

  Dressing

  Suturing & suture Removal


  CPR
  Oro –naso suction
Assisting in advanced nursing procedure

  Lumbar puncture

  Pleural tapping

  Bone marrow aspiration

  Abdominal paracentesis
  Removal of tubes & catheters

  Chest Aspiration
Nursing Clinical Privileges

Name:
Granted
Yes No Clinical Privilege Requested Granted with Denied
Supervision

  Chest tube insertion


  Tracheostomy care
  Ventilator operation
  Ventilator patient care
  Multi Para monitor operation
  Syringe pump operation
  Bi Pap Operation
  C Pap Operation
  Intubations (ACLS )
  Bed Sore dressing
  Cannulating a LBW baby
  Cannulating a New born
  New born care
  Umbilical cord care
  New born CPR
  PV Examination
  Episiotomy stitching
  Labor Monitoring
  Membrane rupture
Others (Please Specify )
 
 
 
 
 

I hereby certify that I am sound by physical and mental health

___________________ ____________ ________


Signature of Applicant Regn. Number Date
Nursing Clinical Privileges

Name:
DO NOT WRITE BELOW THIS LINE

RECOMMENDED BY :

____________________________________
NURSING SUPERINTENDENT

DATE:____________________________

APPROVED BY:

______________________________________________
Chairman, Credentialing & Privileging Committee

DATE:____________________________

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