Specialty: Assistant – Emergency Delineation of Privileges

Applicant's Name:

Instructions:

1. Click the Request checkbox to request a group of privileges such as Primary Privileges or a Privilege Cluster. 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 documentation.

Required Qualifications Membership Meet all requirements for Advanced Practice AHP staff membership

Education/Training Completion of a physician assistant training program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA).

Continuing Education Applicant must have [#] continuing education credits per year directly related to the privileges requested (waived for applicants who have completed training during the previous 24 months)

Certification Current PA-C designation. To attain the PA-C designation, PAs must pass the Physician Assistant National Certifying Exam (PANCE) administered by the National Commission on Certification of Physician Assistants.

Clinical Experience (Initial) Applicant must be able to provide documentation of provision of services (# and type of cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training within the past year).

Clinical Experience Applicant must have provided (# cases) representative of the scope of privileges requested during (Reappointment) the past 24 months

Additional Qualifications Applicant must have a contract with [name of organization/group] to provide services in this specialty OR Applicant must be employed by the organization AND Applicant must have a supervising physician. The supervising physician must be a member of the (--Active--) medical staff in good standing in the Department of (----) OR have privileges in the specialty of (--insert specialty--). AND Current ACLS, PALS and ATLS Certification AND Current DEA Registration with schedules 2, 2N, 3, 3N, 4 and 5

Published: 11/5/2012 8:30:24 AM Physician Assistant – Emergency Medicine Page 1 of 4 [applicant] Published: 11/5/2012 8:30:24 AM

Primary Privileges: Physician Assistant – Emergency Medicine

Description: Physician assistants practice medicine with supervision by licensed and are involved in evaluation, care, stabilization and disposition of patients who present to the as a result of illness and injury. PAs serve in many roles in emergency medicine, including patient triage, patient care in the ED, and selective administrative functions.

Request Request all privileges listed below. Chief Dept Uncheck any privileges that you do not want to request Approval Chair Approval

Medical Screening – perform a medical screening exam. Evaluation – gather essential information about patients to elicit a detailed and accurate history, perform an appropriate physical examination, delineate problems and record or dictate the history and physical in the patient record. Diagnostics – perform and/or interpret, common laboratory, radiologic, cardiographic, and other routine diagnostic procedures used to identify pathophysiologic processes. Therapeutics – Manage simple conditions produced by infection or trauma, and assist in the management of more complex illness and injury, and take initiative in performing evaluative and therapeutic procedures in response to life-threatening situations. Counseling – instruct and counsel patients regarding mental and physical health, including but not limited to diet, disease, prevention, treatment and normal development. Referral – facilitate the referral of patients to the community’s health and social service agencies when appropriate. Also refer and communicate with appropriate consultants in regard to patient management. Write admission orders as requested by the accepting or admitting physician per organization policies and procedures. Administer ordered by supervising physician or self in conformance with organizational policy. Procedures Abscess incision and drainage Administration of medications and injections Advanced Cardiac Life Support including all procedures Advanced Pediatric Life Support including all procedures Advanced Trauma Life Support including all procedures Anoscopy Arterial puncture and blood gas sampling Arthrocentesis Cast and splint application Central line placement Dislocation reduction management Debridement of burns, abrasions and abscesses Epistasix management Extensor tendon repair Fracture reduction Foreign body removal: ears, note, rectum, soft tissue, throat, vaginal Immobilization techniques (spine, long bone, etc.)

Published: 11/5/2012 8:30:24 AM Physician Assistant – Emergency Medicine Page 2 of 4 [applicant] Published: 11/5/2012 8:30:24 AM

Intubation – Endotracheal/nasal Interosseous needle placement Laceration repair – simple, intermediate and complex Local anesthesia Lumbar puncture Nail trephination/removal Nasogastric/Orogastric tube placement, lavage and management Paracentesis Perform routine procedures such as injections, immunizations, suturing and wound care Slit lamp diagnostic and rust ring removal Tonometry, ocular Thoracentesis Thoracostomy tube insertion Urethral catheter placement and management Venous access, peripheral/cutdown

FPPE Retrospective evaluation of (5) cases of patients seen by the PA in the ED admitted to for inpatient medical care. Retrospective evaluation of (5) cases of patients seen by the PA in the ED admitted to for inpatient surgical care. Evaluation from ER Head Nurse/Supervisor. Evaluation of OPPE data collected for review of competency/performance. Data may include: hours worked in ER; procedures performed; complications; patient satisfaction results; etc.

Acknowledgment of Applicant

I have requested only those privileges for which by education, training, current experience, and demonstrated competency I am entitled to perform and that I wish to exercise at Demo Health Services.

I also understand that by making this request, I am bound by the applicable Medical Staff Bylaws and/or policies of Demo Health Services. I also attest that my professional liability insurance covers the privileges I have requested.

I affirm that I will obtain a consultation with a qualified medical staff member when it is in the best interest of the patient and/or when my expertise does not meet the clinical needs of the patient.

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

Department Chair Recommendation - Privileges

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

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

Published: 11/5/2012 8:30:24 AM Physician Assistant – Emergency Medicine Page 3 of 4 [applicant] Published: 11/5/2012 8:30:24 AM

Privilege Condition/Modification/Deletion/Explanation

Department Chair Recommendation - FPPE Requirements

Signature of Chief/Designee Date

Signature of Department Chair/Designee Date

Published: 11/5/2012 8:30:24 AM Physician Assistant – Emergency Medicine Page 4 of 4