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    Nursing Clinical Privileges Department: ICU /NICU /LR

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    KUMARJIT SAHA
    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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    Nursing Clinical Privileges Department: ICU /NICU /LR

    Uploaded by

    KUMARJIT SAHA
    4K views3 pages
    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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    Nursing ICU

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    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.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    4K views3 pages

    Nursing Clinical Privileges Department: ICU /NICU /LR

    Uploaded by

    KUMARJIT SAHA
    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.

    Copyright:

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

    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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