DELINEATION OF CLINICAL PRIVILEGES DEPARTMENT OF INTERNAL MEDICINE

Name: ______

Post applied: ______

(This form should be completed by all Applicants, in order to clearly define the Clinical Privileges to be awarded during the tenure of the above mentioned post. Clinical Privileging is a three-stage process, involving the Applicant, the appropriate Department Director and final verification by the Credentialing and Privileging Committee).

INSTRUCTIONS:

To All Applicants: Tick [Ö] in the “PHYSICIAN’S REQUEST” column, all the items or categories for which you wish to be clinically privileged, based on your qualifications and clinical experience. As regards to items, or categories, for which you do not require clinical privileging, please indicate with a cross [x]. Your signature is required at the end. Once approved, any revisions or corrections to this list of privileges will require you to reapply to the C&P Committee.

To All Department Directors or Immediate Supervisors: Review each category and/or individual privilege marked by the provider and tick the appropriate approval level in the “APPROVED” column whether it is granted (G), Granted with supervision (G/S), or Denied (D), for which the applicant is deemed qualified. This serves as your recommendation to the C&P Committee which holds the approval authority. Your overall recommendation and signature are required at the end. The agreed Privileges will thereafter be presented to the Credentialing and Privileging Committee, for review, before a provisional 90 days approval is granted for the duration of the mandatory probationary 3 month period for all new employees. All Privileges will thereafter be further reviewed at the end of the probationary period, or at the discretion of the C&P Committee, before final approval is granted or withheld, as appropriate.

The C&P Committee reviews each category and/or individual privilege marked by the provider & supervisor and ticks (√) in the C&P Committee Recommendation column the appropriate approval level of each category requested.

C&P Committee Recommendation
Physician’s Request / Principal Clinical Privilege Category Requested / Approved
(Supervisor) / Granted / Granted with Supervision / Denied
q / G G/S D
q q q

(For official use only). Privilege No: ______

Job Title Approved By the C&P Committee:

______Date: _____/_____/_____

(To be filled by the physician in the presence of Human Resources personnel after C&P Committee’s approval).

I have read & understood the clinical privileges granted to me by the C&P Committee and I am constrained by DSFH’s medical staff policies & procedures applicable generally and any applicable to the particular situation.

DSFH ID No: ______Employment date: _____/_____/_____ (Physician’s signature) ______

CLINICAL ATTENDANCE CATEGORY

ü  Emergency and Lifesaving procedures are automatically granted to all Physician Staff.

Physician’s Request / Clinical Privilege Requested / Approved
(Supervisor) / Granted
(G) / Granted with Supervision (G/S) / Denied
(D) /
q / GP Trainee / q
q / General Physician (GP) / q
q / Resident Physician / q
q / Specialist Physician / q
q / Senior Specialist Physician / q
q / Consultant Physician / q
q / Consultant in Sub-specialty / q
q / Consultant in Branch Specialty / q

JOB TITLES

GP Trainee: Bachelor Degree in Medicine and Surgery, or equivalent, as mandatory, in addition to Certificate of Internship.

General Physician: Bachelor Degree in Medicine and Surgery, or equivalent, as mandatory, in addition to Certificate of Internship, with minimum two years post-graduation experience.

Resident Physician: Bachelor Degree in Medicine and Surgery, or equivalent, in addition to Certificate of Internship, with minimum two years experience in the field of specialty, or has obtained a higher qualification, but not yet completed the required period of experience to work as a specialist.

Specialist Physician: Bachelor Degree, as well as a Certificate in the particular field of clinical specialization, having either a Diploma or Master Degree, or equivalent, with two or three years specialized training and not less than one year post specialist certification experience, giving a minimum period of specialized training and experience of four years.

Senior/First Specialist Physician: Bachelor Degree and the Saudi Specialty Certificate, or equivalent, in addition to completing the required clinical experience period (post-training) of up to three years.

Consultant Physician: Must obtain the Saudi Specialty Certificate, or equivalent, and have completed a minimum three years specialized experience.

Consultant in Sub-specialty: Must have obtained a Fellowship within the sub-specialty that its period is of three years after a high qualification or obtaining a Fellowship in sub-specialty of a period of two years after completing an experience of one year in the same specialty, or a training for one year in the sub-specialty in addition to four years experience in the same specialty, or completing an experience in sub-specialty after the high qualification in Specialized Unities in recognized Centers for a period of not less than six years.

Consultant in Branch Specialty: Those who have obtained the Specialty Certificate are qualified to the grade of a Consultant in branch specialty after completing a training program of a period of not less than three years and have completed an experience in the same specialty for a period of four years so that the total period of the training years and the experience is seven years. The title must be in branch specialty exclusively.

Physician’s Request / Clinical Privilege Requested / Approved
(Supervisor) / Granted
(G) / Granted with Supervision (G/S) / Denied
(D) /
q / Admitting Privileges / G G/S D
q q q
GENERAL INTERNAL MEDICINE
q / Abdominal paracentesis / G G/S D
q q q
q / Nasogastric tube insertion / G G/S D
q q q
q / Urinary catheterization / G G/S D
q q q
ENDOCRINOLOGY
q / Needle aspiration of thyroid / G G/S D
q q q
q / Subcutaneous Insulin pump / G G/S D
q q q
GASTROENTEROLOGY
q / Colonoscopy / G G/S D
q q q
q / Colonoscopy with biopsy / G G/S D
q q q
q / Colonoscopy with polypectomy / G G/S D
q q q
q / Colonoscopy with dilatation / G G/S D
q q q
q / Esophagogastroduodenoscopy (EGD) / G G/S D
q q q
q / Esophagogastroduodenoscopy (EGD) with biopsy / G G/S D
q q q
q / Esophagogastroduodenoscopy (EGD) with polypectomy / G G/S D
q q q
q / Enteroscopy / G G/S D
q q q
q / Esophageal dilation / G G/S D
q q q
q / Esophageal sclerotherapy/Band ligation / G G/S D
q q q
q / Esophageal prosthesis / G G/S D
q q q
q / Liver Biopsy / G G/S D
q q q
q / Flexible sigmoidoscopy / G G/S D
q q q
q / Flexible sigmoidoscopy with biopsy / G G/S D
q q q
q / Flexible sigmoidoscopy with polypectomy / G G/S D
q q q
q / Diagnostic ERCP / G G/S D
q q q
q / Therapeutic ERCP / G G/S D
q q q
q / 24-hour pH study / G G/S D
q q q
q / Esophageal manometry / G G/S D
q q q
q / Gastrostomy tube insertion / G G/S D
q q q
HEMATOLOGY
q / Administration of chemotherapy / G G/S D
q q q
q / Bone marrow aspiration and biopsy / G G/S D
q q q
q / Plasmapheresis / G G/S D
q q q
q / Bone Marrow Transplantation / G G/S D
q q q
q / Femoral vein catheter insertion / G G/S D
q q q
q / Central venous catheter insertion / G G/S D
q q q
INFECTIOUS DISEASE
q / Special bacterial culture procedures / G G/S D
q q q
q / Special diagnostic stains / G G/S D
q q q
NEPHROLOGY
q / Hemodialysis / G G/S D
q q q
q / Continuous arterio-venous hemofiltration (CAVH) / G G/S D
q q q
q / Peritoneal dialysis / G G/S D
q q q
q / Preparation and follow up of kidney transplantation / G G/S D
q q q
q / Needle biopsy of kidney / G G/S D
q q q
q / Central venous catheter insertion / G G/S D
q q q
ONCOLOGY
q / Chemotherapy / G G/S D
q q q
q / Radiotherapy / G G/S D
q q q
Intracavitary brachytherapy
q / ·  Tandem and/pr ovoids / G G/S D
q q q
q / ·  Vaginal cylinder / G G/S D
q q q
Interstitial brachytherapy
q / ·  Radioisotope seed implantation / G G/S D
q q q
q / ·  Radioisotope wire implantation / G G/S D
q q q
q / ·  Radioisotope needle implantation / G G/S D
q q q
External beam radiation therapy
q / ·  Linear accelerator – electrons / G G/S D
q q q
q / ·  Linear accelerator – protons / G G/S D
q q q
PULMONOLOGY
q / Mechanical ventilation (support of the patient with respiratory failure) / G G/S D
q q q
q / Needle biopsy of pleura / G G/S D
q q q
q / Thoracocentesis / G G/S D
q q q
q / Flexible tracheoscopy/bronchoscopy / G G/S D
q q q
q / Rigid tracheoscopy/bronchoscopy / G G/S D
q q q
q / Transtracheal aspiration / G G/S D
q q q
q / Pulmonary function tests and interpretation / G G/S D
q q q
q / Interpreting sleep breathing studies / G G/S D
q q q
RHEUMATOLOGY
q / Aspiration of joints for diagnosis and therapy / G G/S D
q q q
q / Punch biopsy of skin and subcutaneous tissue / G G/S D
q q q
q / Intra-articular injection of steroid / G G/S D
q q q
q / Injection of hip joint and costo-vertebral joint ( CT or US guided ) / G G/S D
q q q
DERMATOLOGY & VENREOLOGY
q / Electrocautery of verruca vulgaris / G G/S D
q q q
q / Electrocautery of condyloma accuminata / G G/S D
q q q
q / Chemical cautery of condyloma accuminata / G G/S D
q q q
q / Colloid milia extraction / G G/S D
q q q
q / Cautery and extraction of molluscum contagiosum / G G/S D
q q q
q / Cryocautery using liquid nitrogen / G G/S D
q q q
q / Phototherapy / G G/S D
q q q
q / Skin biopsy / G G/S D
q q q
q / Skin allergy test / G G/S D
q q q
q / Dermojet injection / G G/S D
q q q
q / Intrademal injection of medications / G G/S D
q q q
q / Botox injection for facial wrinkles / G G/S D
q q q
q / Botox injection for hyperhidrosis / G G/S D
q q q
q / Chemical peeling using trichloroacetic acid / G G/S D
q q q
q / Laser Therapy / G G/S D
q q q
q / Dermabrasion, microdermabrasion / G G/S D
q q q
q / Fillers, facial massage, facials / G G/S D
q q q
q / Hair transplantation, tattoos / G G/S D
q q q
q / Resurfacing, mesotherapy / G G/S D
q q q
q / Skin rejuvenation / G G/S D
q q q
OTHER
q / G G/S D
q q q
q / G G/S D
q q q
q / G G/S D
q q q
q / G G/S D
q q q
q / G G/S D
q q q

Applicant Physician: ______/____/____

Name Signature Date

Supervisor/Department Director: ______/____/____

Name Signature Date

C&P Committee Chairman: ______/____/____

Name Signature Date

Director General/Designee: ______/____/____

Name Signature Date

DEPARTMENT OF INTERNAL MEDICINE / N Page 2 of 6