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Physician Credentialing Privilege List

Physician Credentialing Privilege List

Physician Credentialing Privilege List

PROCESS                    

Name of Physician:

Name of Medical Facility:

Code

  1. Perform Unsupervised 
  2. Perform with Supervision
  3. Facility Unable to Support      
  4. Not Requested 
  5. 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