UNIVERSITYHOSPITAL

RADIOLOGYNURSE 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 performancefrom the hospital’s Chief of Staff, Department Chair, or Supervising Physician.

The reappointment applicant must demonstratecontinuing 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 oftraining in

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

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

and the Governing Board of UniversityHospital.

RADIOLOGY NURSE PRACTITIONER

REQUEST FOR PRIVILEGES

PAGE 2

SPECIAL PRIVILEGES to include: REQUESTEDGRANTED

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.

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Applicant’s SignatureDateApplicant’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 UniversityHospital. 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.

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Supervising Physician’s SignatureDatePhysician’s Printed Name

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Supervising Physician’s SignatureDatePhysician’s Printed Name