nurse practitioner soin & greene - kettering health network · nurse practitioner soin &...

Nurse Practitioner Soin & GreeneDelineation of Privileges

Applicant's Name:

Instructions:

1. Click the Request checkbox to request a group of privileges.

2. Uncheck any privileges you do not want to request in that group.

3. Check off any special privileges you want to request.4. Sign/Date form and Submit with required documentation5. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving doubts related to qualification of requested privileges.

NOTE: Privileges granted may only be exercised at the site(s) and setting(s) that have the appropriate equipment, license, beds, staff,and other support required to provide the services defined in this document. Site-specific services may be defined in hospital ordepartment policy.

This document is focused on defining qualifications related to competency to exercise clinical privileges. The applicant must alsoadhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet.

Required Qualifications

Membership Each specialty and/or supervising/collaborating physician is responsible for submitting a list ofprivileges, which are not otherwise identified in this document, and that are within the supervisingphysician's normal course and scope of practice. This specific list will be approved by the AlliedHealth Professionals Council, the Credentials Committee and the Medical Executive Committee.An approved list will then be included in each NP's application. If special duties, not included onthe list, are requested they must be approved by the above committees.

ANDTo be eligible to apply for clinical privileges as a nurse practitioner, the applicant must meet thefollowing criteria:

Education/Training Licensed registered nurse in the State of Ohio, with a Master's Degree in the specialty and holdsan Ohio certificate of authority to practice as a CNP

Certification Successfully passed the certification exam of the American Nurses Credentialing Center, or othercertifying organizations approved by the Ohio Board of Nursing relative to the CNPs designatedspecialty (i.e. Neonatology).

ANDFor prescriptive privileges, a Certificate to Prescribe is required

Clinical Experience (Initial) Applicants for initial appointment must be able to demonstrate provision of care, treatment, orservices reflective of the scope of privileges requested to at least 25 patients in the past 12months, or completion of master's or post master's degree program in the past 12 months.

Published: [pubdate Nurse Practitioner Soin & Greene of 14

Clinical Experience(Reappointment)

Current demonstrated competence and an adequate volume of experience 25 patients withacceptable results in the privileges requested for the past 24 months based on results of ongoingprofessional practice evaluation and outcomes. Evidence of current ability to perform privilegesrequested is required of all applicants for renewal of privileges.

Note The privileges of a Nurse Practitioner may be terminated at the direction of the clinical servicechief in which the supervising/collaborating physician is a member or the Chief of Staff at any timefor just and due cause. The supervising physician may appeal this termination to the MedicalExecutive Committee or a committee especially dedicated for this purpose. Privileges arevoluntarily resigned upon leaving the employment of the supervising/collaborating physician(s).

ANDPractices only in accordance with a Standard Care Arrangement entered into with one or morecollaborating physicians who are continuously available to communicate with the CNP either inperson or by radio, telephone, or other form of telecommunication. It is the responsibility of theCNP and collaborating physician to provide Medical Staff Services with a copy of the original andany revisions to the Standard Care Arrangement.

ANDProfessional liability insurance coverage issued by a recognized company and of a type and in anamount equal to or greater than the limits established by the governing body

[applicant]


Primary Privileges Nurse Practitioner

Description: Manages the healthcare of acutely ill, chronically ill, and critically ill patients within the age group ofthe collaborating/supervising physician. NPs may not admit patients to the hospital. May provide care to patients inthe intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition ofpatients with emergent conditions consistent with medical staff policy regarding emergency and consultative callservices. The core privileges in this specialty include the procedures on the attached procedure list and such otherprocedures that are extensions of the same techniques and skills.

Qualifications

Medical record chartingresponsibilities

Clearly, legibly, completely, and in a timely fashion, the NP must describe each service providedto a patient in the hospital and describe relevant observations. Standard rules regardingauthentication of, necessary content of, and required time frames for preparing and completing themedical record and portions thereof are applicable to all entries made.

Request Request all privileges listed below.

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IN Click shaded blue check box to Request all privileges.Uncheck any privileges you do not want to request.

- Currently granted privileges

Core Privileges (Includes as applicable: allergy/immunology, endocrinology, family medicine, gastroenterology,hematology/oncology, infectious disease, internal medicine, physical medicine and rehabilitation, pulmonarymedicine, and rheumatology)

Demonstration of appropriate airway management (see hospital policy)Appraise health risks andbehaviorsApply, remove, and change dressings and bandagesCounsel and instruct patients and significant others as appropriateDiagnose and manage commonly occurring health and disease related symptomsDictate H & P'sDirect care as specified by medical staff approved protocolsEducate and counsel patients covering such things as health status, test results, disease processes, anddischarge planningInitiate referral to consultant physician or other healthcare professional of problems that exceed the NP'sscope of practiceInsert and remove nasogastric tubesInitiate referral to appropriate physician or other healthcare professional of problems that exceed the NP'sscope of practiceIndependent assessment and disposition of low acuity patientsMake daily rounds on hospitalized patients with or at the direction of the collaborating/supervisingphysicianAssess, diagnose, treat and observe patient responses relevant to stable acute and chronic illnesses ofthe population servedObtain and record medical/social history and perform physical examinations including rectal and pelvicexaminations as indicatedOrder diagnostic testing and therapeutic modalities such as laboratory tests, medications, treatments,X-ray, EKG, IV fluids and electrolytes, etc.Perform consultations and document

[applicant]


Perform field infiltrations of anesthetic solutionsPerform incision and drainage of superficial abscessesPerform site checks after placement of catheters or pacemakersPerform urinary bladder catheterization (short-term and indwelling) (e.g., Robinson, coudé, Foley)Perform venous punctures for blood sampling, cultures, and IV catheterizationPerform wound debridement and general care for superficial wounds and minor superficial surgicalprocedures, including suturingProvide admission and discharge ordersProvide care to critical and non-critical patientsProvide preliminary interpretation of EKGRecord progress notesRecord discharge summaries

Nurse Practitioner (NP) Core Privileges — Cardiovascular Disease

Description: Provide comprehensive care to patients diagnosed with cardiovascular disease and identified asat-risk for cardiac vascular events within the age group of patients seen by the collaborating/supervising physician.NPs may not admit patients to the hospital. May provide care to patients in the intensive care setting inconformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditionsconsistent with medical staff policy regarding emergency and consultative call services. The core privileges in thisspecialty include the procedures on the attached procedure list and such other procedures that are extensions ofthe same techniques and skills.


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Monitor chest painPerformance of pharmacological/non-pharmacological stress tests

[applicant]


Nurse Practitioner (NP) Core Privileges — Critical Care

Description: Management of care including risk appraisal, interpretation of diagnostic tests, providing treatment,and prescribing medication for patients with complex needs who are critically ill within the age group of patientsseen by the collaborating physician. NPs may not admit patients to the hospital. Assess, stabilize, and determinethe disposition of patients with emergent conditions consistent with medical staff policy regarding emergency andconsultative call services. The core privileges in this specialty include the procedures on the attached procedure listand such other procedures that are extensions of the same techniques and skills.


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Insert arterial cathetersInsert central venous cathetersInsert chest tubesInsert pulmonary artery cathetersOrder and perform initial interpretations of simple plain X-ray films with second reading bycollaborating/supervising physician (or radiologist)Perform endotracheal extubation and intubationPerform lumbar punctures

Nurse Practitioner (NP) Core Privileges - Emergency Medicine

Description: Assess, evaluate, diagnose, and initially treat patients of all ages who present in the ED with anysymptom, illness, injury, or condition, and provide services necessary to ameliorate minor illnesses or injuries.Stabilize patients with major illnesses or injuries and assess all patients to determine if additional care is necessary.Privileges do not include long-term care of patients on an inpatient basis. No privileges to admit or performscheduled elective procedures with the exception of procedures performed during routine emergency roomfollow-up visits. The core privileges in this specialty include the procedures on the attached procedure list and suchother procedures that are extensions of the same techniques and skills.

Request Request all privileges listed below.G

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Arthrocentesis and joint aspirationsPerform lumbar punctureInsert thoracostomy tubesChange G-tubesChange tracheostomy tubesDiagnostic lumbar punctures

[applicant]


FAST ultrasoundInsert Heimlich (small gauge) valveInterosseous accessLaceration repairLocal/digital anesthesiaManage epistaxisOcular tonometryPerform arterial puncture and blood gas samplingPerform intubationPerform preliminary interpretations of simple plain X-ray films with second reading by supervisingphysician (or radiologist)Peripheral arterial/peripheral and central venous accessReduce joint dislocationsPerform removal of foreign body (ears, nose, rectum, vagina, throat, and soft tissue)Superficial foreign body removal from corneaTrephination and removal of nailAssist the ER physician in any other action delegated by the physician under direct supervision of thephysician

Nurse Practitioner (NP) Core Privileges - Neonatology

Description: Evaluate, diagnose, and provide care, treatment, and services consistent with neonatal/perinatalpractice for well babies. NPs may not admit patients to the hospital. Assess, stabilize, and determine the dispositionof patients with emergent conditions consistent with medical staff policy regarding emergency and consultative callservices. The core privileges in this specialty include the procedures on the attached procedure list and such otherprocedures that are extensions of the same techniques and skills.


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Order and obtain samples for appropriate studies and discuss results with neonatologist. Instituteappropriate action subsequent to conference with the neonatologist.Order the use and discontinuation of phototherapy subsequent to conference with the neonatologistPerform newborn physical examinations using the techniques of observation, inspection, auscultation,palpation, and percussionPerform routine immunizationsPerform screenings of Auditory Brainstem Responses (ABRs)Provide immediate supportive care of the newborn in the delivery roomReview maternal health, labor, and delivery records of all infants admitted to newborn nursery under theservice of the neonatology group

[applicant]


Nurse Practitioner (NP) Core Privileges - Neurology

Description: Provide care, treatment, and services consistent with neurology practice, including the performance ofphysical exams, diagnosing conditions, the development of treatment plans, health counseling, and prescribingmedications in accordance with state law for patients within the age group of patients seen by thecollaborating/supervising physician. NPs may not admit patients to the hospital. May provide care to patients in theintensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patientswith emergent conditions consistent with medical staff policy regarding emergency and consultative call services.The core privileges in this specialty include the procedures on the attached procedure list and such otherprocedures that are extensions of the same techniques and skills.


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Lumbar Puncture

Nurse Practitioner (NP) Core Privileges - Neurosurgery

Description: Management of care for patients undergoing neurosurgery procedures within the age group seen bythe collaborating physician to include pre-, intra-, and postoperative care, the performance of physical exams,diagnosing conditions, the development of treatment plans, health counseling, prescribing medications inaccordance with state law, and assisting in surgery. NPs may not admit patients to the hospital. Provide care topatients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine thedisposition of patients with emergent conditions consistent with medical staff policy regarding emergency andconsultative call services. The core privileges in this specialty include the procedures on the attached procedure listand such other procedures that are extensions of the same techniques and skills.


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Manage intracranial monitorsRemove cranial and spinal drainsPerform lumbar puncturePlace Halo fixationPlace intracranial pressure monitorPlace external ventricular drains

[applicant]


Nurse Practitioner (NP) Core Privileges - Pediatrics

Description: Provide care, treatment, and services consistent with pediatric practice, including the performance ofphysical exams, diagnosing conditions, the development of treatment plans, health counseling, and prescribingmedications for patients within the age group of patients seen by the collaborating/supervising physician. NPs maynot admit patients to the hospital. May provide care to patients in the intensive care setting in conformance with unitpolicies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent withmedical staff policy regarding emergency and consultative call services. The core privileges in this specialty includethe procedures on the attached procedure list and such other procedures that are extensions of the sametechniques and skills.


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Lumbar Puncture

Nurse Practitioner (NP) Core Privileges - Psychiatric and Mental Health


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Clinically manage psychiatric disorders including but not limited to severe and persistent neurobiologicaldisordersConduct individual, group, and family psychotherapy

[applicant]


Nurse Practitioner (NP) Core Privileges - Orthopedic Surgery

Description: Provide care, treatment, and services consistent with orthopedic surgery practice including theperformance of physical exams, diagnosing conditions, the development of treatment plans, health counseling,prescribing medications in accordance with state law, and assisting in surgery for patients within the age group ofpatients seen by the collaborating/supervising physician. NPs may not admit patients to the hospital. May providecare to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine thedisposition of patients with emergent conditions consistent with medical staff policy regarding emergency andconsultative call services. The core privileges in this specialty include the procedures on the attached procedure listand such other procedures that are extensions of the same techniques and skills.


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Administer digital blockApplication of casts and/or splintsApplication of skeletal traction pin to tibia or femurClosed reduction of fracture or dislocation of the elbow, wrist, ankle, hip and shoulderInjection of steroids preparation into the following joints shoulder, elbow, wrist, hip & knee plus,subacromial bursa, lateral & medial epicondyle tendon insertion about the elbow, greater trochantericbursa, and olecranon bursaOrder orthopedic devices as allowed by state legislationPerform arthrocentesis of: shoulder, elbow, wrist, hip and kneePerform compartment pressure measurements

[applicant]


Nurse Practitioner (NP) Core Privileges - Surgical

Description: Evaluate, diagnose, and provide pre-, intra- and postoperative care, treatment, and servicesconsistent with surgical practice, including the performance of physical exams, diagnosing conditions, thedevelopment of treatment plans, health counseling, prescribing medications, and assisting in surgery for patientswithin the age group of patients seen by the collaborating/supervising physician. NPs may not admit patients to thehospital. May provide care to patients in the intensive care setting in conformance with unit policies. Assess,stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policyregarding emergency and consultative call services. The core privileges in this specialty include the procedures onthe attached procedure list and such other procedures that are extensions of the same techniques and skills.


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Insert central venous cathetersPerform anoscopySelect and apply appropriate wound dressings, including liquid or spray occlusive materials, absorbentmaterial affixed with tape or circumferential wrapping, immobilizing dressing (soft or rigid), or medicateddressings

[applicant]


Special Non Core Procedures Nurse Practitioner (NP)

Qualifications

Education/Training Those technical and management skills that qualify the NP to administer highly specialized careby virtue of training and experience

Clinical Experience (Initial) Demonstrated current competence and evidence of the performance of at least 5 procedures inthe past 12 months or direct supervision is required for the first 5 procedures for each privilegerequested


Demonstrated current competence and evidence of the performance of at least 5 procedureswithin the past 24 months based on results of ongoing professional practice evaluation andoutcomes


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Insert arterial cathetersInsert central venous cathetersInsert pulmonary artery cathetersPerform lumbar puncturePerform IntubationThoracentesis

[applicant]


Insert Thoracostomy Tube

Qualifications

Education/Training Those technical and management skills that qualify the NP to administer highly specialized careby virtue of training and experience.

Clinical Experience (Initial) Demonstrated current competence and evidence of the performance of at least 4 procedures inthe past 12 months or direct supervision is required for the first 4 procedures.


Demonstrated current competence and the performance of at least 4 procedures in the past 24months based on results of ongoing professional practice evaluation and outcomes.


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Insert thoracostomy tube

Performance of Pharmacological and Non-Pharmacological Stress Tests

Qualifications

Education/Training Those technical and management skills that qualify the NP to administer highly specialized careby virtue of training and experience

Clinical Experience (Initial) Demonstrated current competence and evidence of the performance of at least 20 procedures inthe past 12 months or direct supervision is required for the first 20 procedures.


Demonstrated current competence and the performance of at least 20 procedures in the past 24months based on results of ongoing professional practice evaluation and outcomes.


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Performance of pharmacological and non-pharmacological stress tests

[applicant]


Prescriptive Authority as Delegated by a Physician in a Written Agreement in Accordance withState and Federal Law

Qualifications

Note The delegation to the Nurse Practitioner to administer or dispense drugs shall include theprescribing of controlled substances in accordance with the Ohio State Nurse Practice Act and itsestablished formulary.


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Prescriptive Authority as Delegated by a Physician in a Written Agreement in Accordance with State andFederal Law

Acknowledgment of Applicant

I have requested only those privileges for which by education, training, current experience, and demonstrated competency I believe that I am competent to perform and that I wish to exercise at Greene Memorial Hospital and/or Soin Medical Center, and I understand that:

A. In exercising any clinical privileges granted, I am constrained by applicable Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.

B. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.

Practitioner's Signature Date

Clinical Service Chief Recommendation - Privileges

I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):

Recommend all requested privilegesDo not recommend any of the requested privilegesRecommend privileges with the following conditions/modifications/deletions (listed below)

[applicant]


Privilege Condition/Modification/Deletion/Explanation

Clinical Service Chief Recommendation - Additional Comments

Clinical Service Chief Signature Date

[applicant]


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