UC Davis, Student Health and Counseling Services 180-02Appointment & Reappointment /AHP

Attachment 4 – Privilege form for NP

NURSE PRACTITIONER PRIVILEGE DELINEATION FORM

This privilege form describes the qualifications related to competency to exercise the defined clinical privileges that may be requested by a qualified practitioner based on the training and experience required. Privileges granted may only be exercised at the site(s) and setting(s) that have the appropriate equipment, staff, and other support required to provide the services defined in this document. Delegated medical functions may be performed in accordance with written, Standardized Procedures of the organization as defined by California regulation. The applicant must also adhere to any additional organizational, regulatory, or accrediting requirements that this facility is obligated to meet. The exercise of these privileges requires a collaborating physician who must be available onsite in the clinical practice or available by electronic or telephone means as specified in local protocols and procedures.

Instructions: Please check off the “Requested” box for all privileges requested. If you wish to exclude any procedures, please strikethrough, initial and date those procedures that you DO NOT wish to request.

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UC Davis, Student Health and Counseling Services 180-02Appointment & Reappointment /AHP

Attachment 4 – Privilege form for NP

NURSE PRACTITIONER PRIVILEGE DELINEATION FORM

NAME :

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UC Davis, Student Health and Counseling Services 180-02Appointment & Reappointment /AHP

Attachment 4 – Privilege form for NP

NURSE PRACTITIONER PRIVILEGE DELINEATION FORM

Requested / Approved / Privileges / Initial Criteria / Renewal Criteria
 /  / CORE PRIVILEGES
Core privileges include, but are not limited to:
Performance of history and physical examinations.
Development of treatment plans
Ordering of diagnostic tests and therapeutic modalities such as medications, treatments, and subspecialty consultations.
Performance of delegated medical functions as defined by the written Standardized Procedures for Nurse Practitioners of the SHS and organizational policies and procedures.
Educating , counseling, instructing patients concerning health status, results of tests, disease process and health maintenance.
Microscopy (skin KOH, vaginal wet prep)
IUD removal
IV Fluid Administration
Destruction of skin lesion / Current, active, unrestricted California Registered Nurse License; AND
Current, active, unrestricted California Nurse Practitioner certification; AND
Successful completion of an accredited Nurse Practitioner program; AND
Current state furnishing number AND
DEA certificate with schedules
lII-V.
Education and training to support setting and patient population AND
Current BLS
Initial review of 30 medical records which may be a combination of concurrent and retrospective chartreviews to be completed within one month by the proctor and/or peer review committee. Additional charts may be required at the discretion of the Medical Director.
Initial review to be completed within a one month time interval.If necessary, this timeline may be extended not to exceed one month. / Core privileges are renewed with reappointment.
Maintenance of active, unrestricted California licensure, and other licensure/practice requirements as defined in the initial application; AND
Current demonstrated competency as evidenced by satisfactory quality/peer review of a minimum of 15 medical records/3 year reappointment period.
Demonstrated ability to work well with patients and staff as reflected in the periodic performance evaluation.
Annual competency testing for
Microscopy (skin KOH, vaginal wet prep)
SPECIALIZED PRIVILEGES / Criteria / Renewal Criteria
Check privilege being requested: /
  • Credentials as outlined above; AND
  • Documented training OR1 peer reference that attests to current clinical competency (within the past 3 Years) in requested special privileges; AND
  • Observation of 1 procedure performed by a qualified proctor*, AND
  • Concurrent observation of 3 procedures with a qualified proctor* present AND retrospective chart review of 3 procedures until competency is confirmed.
  • For Implanon/Nexplanon removal, concurrent observation of 1 procedure with a qualified proctor* present AND retrospective chart review of 3 procedures until competency is confirmed.
*Qualified Proctor: SHCS provider currently privileged for the respective privilege and approved by the Medical Director to proctor.
Continued on next page. / Meet the requirements listed above
AND for Specialized Privileges:
Must have successfully performed at least 5 procedures in the past three (3) years or certification of competency by Medical Directorto maintain this privilege.
Continued on next page.
 /  / Repair of superficial cutaneous lacerations with use of topical or local infiltration anesthetic administration (excludes complicated, deep tissue repairs of muscle, tendon, nerve, blood vessels or other deep tissue structures)
 /  / Incision and drainage of localized cutaneous abscesses
 /  / Dermatologic intralesional injection except face
 /  / Dermatologic intralesional injection of face
 /  / Initial management of uncomplicated minor closed fractures, splint application (excludes application of circular casting)
Continued on next page.
 /  / SPECIALIZED PRIVILEGES (continued)
Nail excision / Criteria (continued)
OR, If currently privileged for the identified special privilege at UCDHS or at an acceptable institution (acceptable per medical director), completion of 1 observed procedure by qualified proctor*, AND 1 concurrent proctoring by qualified proctor* until competency is confirmed for the special privilege requested.
NOTE: Individuals who do not meet the above initial criteria for the special privilege being requested may be considered on a case-by-case basis upon evaluation by Medical Director in consultation with Peer Review Chair and a qualified physician proctor* with the current privilege.
*Qualified Proctor: SHCS provider currently privileged for the respective privilege and approved by the Medical Director to proctor. / Renewal Criteria
Meet the requirements listed above
AND for Specialized Privileges:
Must have successfully performed at least 5 procedures in the past three (3) years or certification of competency by Medical Directorto maintain this privilege.
 /  / Removal of foreign body, subcutaneous, simple
 /  / IUD Insertion
 /  / Implanon/Nexplanon Insertion
 /  / Implanon/Nexplanon removal*
 /  / Cyst and soft tissue injection
 /  / BartholinCyst Incision & Drainage including placement of WORD catheter

 / 
 / Shave / Punch Biopsy
Local Anesthesia
  • Digital block
  • Topical
______
OTHER - SPECIFY

 / 

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UC Davis, Student Health and Counseling Services 180-02Appointment & Reappointment /AHP

Attachment 4 – Privilege form for NP

NURSE PRACTITIONER PRIVILEGE DELINEATION FORM

I certify that I have had the necessary training and experience to perform the procedures that I have requested. The burden of producing information deemed adequate by the organization for a proper evaluation of current competence, current clinical activity and other qualifications and for resolving any doubts related to qualifications for the requested privileges is mine. I have reviewed all the criteria that pertain to those privileges that I am requesting and I certify that I meet those criteria.

In exercising the privileges granted to me, I agree to strictly abide by the facility’s Credentialing Policies and Procedures. I acknowledge that any restrictions on the clinical privileges granted to me are waived in an emergency/disaster situation involving threat to patient life, recognizing that immediately upon stabilization of the patient, I shall obtain the services of an appropriately credentialed and privileged practitioner to care for the patient.

Applicant’s Name (Print) / Signature /Date

I have reviewed the applicant’s credentials, experience, training, health status, current competence and peer recommendations relative to this request for privileges. The following recommendations are made:

RECOMMENDATIONS/APPROVAL

Supervisor______Date ___/____/____ Recommended

Medical Director ______Date ___/____/____ Recommended

Peer Review Chair______Date ___/____/____ Recommended

Executive Director______Date ___/____/____ APPROVED DENIED DEFERRED

Privileges Effective: From ___/____/____ to ___/____/____ (not to exceed appointment date)

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