Physician Credentialing Privilege List

Last updated on 2/8/19 | First published on 10/20/17 | Literature review current through Oct. 2024 [cite]

Authors: Jeff Mize RRT, CHT, UHMSADS, Tiffany Hamm BSN, RN, CWS, ACHRN, UHMSADS, Topic editors: Eugene Worth MD, M.Ed., FABA, ABPM/UHM, more...

PROCESS

Name of Physician:

Name of Medical Facility:

Code

Perform Unsupervised
Perform with Supervision
Facility Unable to Support
Not Requested
Not approved

	Privilege LIST	Requested	Code	Approved
A.	Provide Hyperbaric Management
1	Decompression Illness
2	Carbon Monoxide Poisoning/Smoke Inhalation
3	Gas Embolism
4	Gas Gangrene
5	Necrotizing Soft Tissue Infections
6	Crush Injury/Compartment Syndrome/ Traumatic Ischemias
7	Radiation Tissue Damage
8	Compromised Grafts and Flaps
9	Problem/Compromised Wounds
10	Osteomyelitis
11	Thermal Burns
12	Brain Abscess
13	Other UHMS Accepted Indications
14	Hyperbaric Medicine Complications (Barotrauma, Oxygen Toxicity, etc.)
15	Apply Standard Treatment Schedules and Modify when Clinically Indicated.
B.	Primary Procedures
1	Minor Surgical Debridement of Wounds
2	Transcutaneous Oximetry Interpretation
3	Complicated Wound management
4	Local and Regional Anesthesia
5	Wound Biopsy
6	Emergency Myringotomy
7	Endotracheal Intubation
8	Simple Laceration Repair
9	Emergency Chest Tube Placement
C.	Other Procedures
1	Major Surgical Debridement of Wounds
2	Pinch Grafts
3	Split Thickness Skin Grafts
4	Elective PE Tube Placement
5	Central Line Placement
D.	All Safety and Compliance from Previous 12 months Completed	YES		NO

RECOMMENDATION

 Recommend Approval

 Recommend Approval with Modifications (specify)

 Recommend Disapproval (specify)

The approved privileges will expire on: ______________________

Signature of Medical Director ______________________________________ Date: _________

Signature of Safety Director _______________________________________ Date: _________

Policy Effective Date:

Reviewed Date:

Revised Date:

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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

Topic 54 Version 2.0

Physician Credentialing Privilege List

Physician Credentialing Privilege List

PROCESS

Name of Physician:

Name of Medical Facility:

RECOMMENDATION

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