HEALTH CITY HOSPITAL, GUWAHATI

(A unit of North East Health City Pvt. Ltd.) HCH/TECH/Fm-

Clinical Privileges for Nurses

Emergency Privileges:
In case of an emergency, Technician staff member is authorized to do anything possible to save patient’s life
or save a patient from serious harm.
Acknowledgement of Technician staff:
I have requested only those privileges for which by education, training, current experience and demonstrated
performance I am qualified to perform and for which I wish to exercise at my profession.
In exercising any clinical privileges granted, I am constrained by Hospital and medical staff policies and rules
applicable generally and applicable to the particular situation.
Name: _________________________________________ Registration No. _________________________
Signature with date: ______________________________________________________________________

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Proposed and Reviewed by Reporting Head:_______________________________________________
HEALTH CITY HOSPITAL, GUWAHATI
Sign of Consultant Quality: _____________________________________________________________
(A unit
Sign Of Nursing Superintendent: of North East Health City Pvt. Ltd.) HCH/TECH/Fm-
________________________________________________________
(Authorized) Signature of Medical Director / D-MS / MS: _____________________________________
Clinical Privileges for Nurses

Clinical Privileges (0-3YEARS)

Tick Cross
Mark Mark
Nurse in Surgical ICU Clinical Privileges Requested Granted Denied
1. Monitors exact, detailed reports and records of the critical ICU
patients.
2. Monitors and records symptoms and changes in patients’
conditions and information to the physician.
3. Carefully observes and documents patients medical information
and vital signs.
4. Documents patients’ treatment plans, interventions, outcomes, or
plan revisions.
5. Adheres to hospital infection control protocols and policies
while providing patient care.
6. Consults and coordinates with health care team members about
whole patient care plans.
7. Is competent in Modifying patient treatment plans as indicated
by patient’s response and conditions.
8. Monitors the critical patients for changes in status and
indications of conditions such as sepsis or shock and institute
appropriate interventions.
9. Is able to assess patients’ pain levels and sedation requirements.
10. Accurately Prioritize nursing care for assigned critically ill
patients based on assessment data and identified needs.
11. Communicates and Provides education and support to patient
families.
12. Is able to draw blood for ABG analysis.
13. Is Knowledgeable on drug and fluid calculation.
14. Is Knowledgeable about management on ventilator care.
15. Knowledgeable about management of Drains/ICD/Invasive
devices.
16. Is knowledgeable of Isolation and Barrier nursing.
17. Initiates CPR and activates code blue as and when required
18. Is knowledgeable about various other codes of the hospital (code
red, code pink, code yellow, code violet).
19. Has undergone BLS and ACLS training.

Proposed and Reviewed by Reporting Head:_______________________________________________

Sign of Consultant Quality: _____________________________________________________________
Sign Of Nursing Superintendent: ________________________________________________________
(Authorized) Signature of Medical Director / D-MS / MS: _____________________________________

Clinical Privileges (3-6years)

Tick Cross
Mark Mark
Nurse in Surgical ICU Clinical Privileges Requested Granted Denied
1. Monitors exact, detailedPage 2 of 7and records of the critical ICU
reports
patients.
 HEALTH CITY HOSPITAL, GUWAHATI
(A unit of North East Health City Pvt. Ltd.) HCH/TECH/Fm-

Clinical Privileges for Nurses

Proposed and Reviewed by Reporting Head:_______________________________________________

Sign of Consultant Quality: _____________________________________________________________
Sign Of Nursing Superintendent: ________________________________________________________
(Authorized) Signature of Medical Director / D-MS / MS: _____________________________________

Clinical Privileges (3-6years)

Tick Cross
Mark Mark
Nurse in Surgical ICU Clinical Privileges Requested Granted Denied

Page 3 of 7
 HEALTH CITY HOSPITAL, GUWAHATI
(A unit of North East Health City Pvt. Ltd.) HCH/TECH/Fm-

Clinical Privileges for Nurses

1. Monitors exact, detailed reports and records of the critical ICU
patients.
2. Monitors and records symptoms and changes in patients’
conditions and information to the physician.
3. Carefully observes and documents patients medical information
and vital signs.
4. Documents patients’ treatment plans, interventions, outcomes, or
plan revisions.
5. Consults and coordinates with health care team members about
whole patient care plans.
6. Is competent in Modifying patient treatment plans as indicated
by patient’s response and conditions.
7. Monitors the critical patients for changes in status and
indications of conditions such as sepsis or shock and institute
appropriate interventions.
8. Adheres to hospital infection control protocols and policies
while providing patient care.
9. Is able to assess patients’ pain levels and sedation requirements.
10. Accurately Prioritize nursing care for assigned critically ill
patients based on assessment data and identified needs.
11. Is assertive as a patient advocate
12. Communicates and Provides education and support to patient
families.
13. Is able to draw ABG Blood and interpret the report correctly.
14. Efficiently follows continuous cardiac and respiratory monitor
readings, such as EKG tracings, O2 stats, CVP/arterial line
waveforms, if applicable, and reports any observed changes.
15. Demonstrates knowledge and skills on intubation, extubation
and weaning.
16. Is Knowledgeable on drug and fluid calculation.
17. Demonstrates skill on E.T & Tracheotomy suctioning &
handling of high end equipment.
18. Is Knowledgeable about management on ventilator care.
19. Knowledgeable about management of Drains/ICD/Invasive
devices.
20. Is knowledgeable of Isolation and Barrier nursing.
21. Demonstrates post-operative exercises to the patient. E.g. pursed
lip breathing, guarding,coughing and deep breathing.
22. Demonstrates skill on nursing care of hemodynamically
compromised patients.
23. Initiates CPR and activates code blue as and when required
24. Is knowledgeable about various other codes of the hospital (code
red, code pink, code yellow, code violet).
25. Has undergone BLS and ACLS training.

Page 4 of 7
HEALTH CITY HOSPITAL, GUWAHATI
(A unit of North East Health City Pvt. Ltd.) HCH/TECH/Fm-

Clinical Privileges for Nurses

Page 5 of 7
Proposed and Reviewed by Reporting Head:_______________________________________________
HEALTH CITY HOSPITAL, GUWAHATI
Sign of Consultant Quality: _____________________________________________________________
(A unit
Sign Of Nursing Superintendent: of North East Health City Pvt. Ltd.) HCH/TECH/Fm-
________________________________________________________
(Authorized) Signature of Medical Director / D-MS / MS: _____________________________________
Clinical Privileges for Nurses

Clinical Privileges (>6years)

Tick Cross
Mark Mark
Nurse in Surgical ICU Clinical Privileges Requested Granted Denied
1. Monitors exact, detailed reports and records of the critical ICU
patients.
2. Monitors and records symptoms and changes in patients’
conditions and information to the physician.
3. Carefully observes and documents patients’ medical information
and vital signs.
4. Documents patients’ treatment plans, interventions, outcomes, or
plan revisions.
5. Consults and coordinates with health care team members about
whole patient care plans.
6. Is competent in Modifying patient treatment plans as indicated
by patient’s response and conditions.
7. Monitors the critical patients for changes in status and
indications of conditions such as sepsis or shock and institute
appropriate interventions.
8. Adheres to hospital infection control protocols and policies
while providing patient care.
9. Is able to assess patients’ pain levels and sedation requirements.
10. Accurately Prioritize nursing care for assigned critically ill
patients based on assessment data and identified needs.
11. Is assertive as a patient advocate.
12. Communicates and Provides education and support to patient
families.
13. Is able to draw ABG Blood and interpret the report correctly.
14. Efficiently follows continuous cardiac and respiratory monitor
readings, such as EKG tracings, O2 stats, CVP/arterial line
waveforms, if applicable, and reports any observed changes.
15. Demonstrates knowledge and skills on intubation, extubation
and weaning.
16. Is Knowledgeable on drug and fluid calculation
17. Demonstrates skill on E.T & Tracheotomy suctioning &
handling of high end equipment.
18. Is Knowledgeable about management on ventilator care.
19. Knowledgeable about management of Drains/ICD/Invasive
devices.
20. Is knowledgeable of Isolation and Barrier nursing.
21. Demonstrates post-operative exercises to the patient. E.g. pursed
lip breathing, coughing and deep breathing.
22. Demonstrates skill on nursing care of hemodynamically
compromised patients.
23. Initiates CPR and activates code blue as and when required
24. Is knowledgeable about various other codes of the hospital (code
red, code pink, code yellow, code violet).
25. Has undergone BLS and ACLS training.
26. Utilizes clinical reasoning to form sound professional judgement
in practice and consult as required.
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27. Actively involved in quality assurance activities to improve the
HEALTH CITY HOSPITAL, GUWAHATI
(A unit of North East Health City Pvt. Ltd.) HCH/TECH/Fm-

Clinical Privileges for Nurses

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