Scribd Logo
Upload

Welcome to Scribd!

  • Clinical Privileges Form

    Uploaded by

    rinrin mulyati
    52 views2 pages
    This document is a clinical privileges form for a specialist anesthesiologist. It lists 5 clinical competencies and requests the physician to indicate which competencies they are requesting and provides space for comments. The medical committee will then review the requests, indicate approval or denial of each competency, and provide any comments. If approved, the competencies granted will define the clinical scope of practice for the physician.

    Original Description:

    form kewenangan klinis anasthesi

    Original Title

    2 Form Kewenangan Klinis - Dr Anestesi

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is a clinical privileges form for a specialist anesthesiologist. It lists 5 clinical competencies and requests the physician to indicate which competencies they are requesting and provides space for comments. The medical committee will then review the requests, indicate approval or denial of each competency, and provide any comments. If approved, the competencies granted will define the clinical scope of practice for the physician.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    52 views2 pages

    Clinical Privileges Form

    Uploaded by

    rinrin mulyati
    This document is a clinical privileges form for a specialist anesthesiologist. It lists 5 clinical competencies and requests the physician to indicate which competencies they are requesting and provides space for comments. The medical committee will then review the requests, indicate approval or denial of each competency, and provide any comments. If approved, the competencies granted will define the clinical scope of practice for the physician.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    FORMULIR KEWENANGAN KLINIS

    IDENTITAS :
    Nama
    Tempat / tanggal lahir
    Diajukan untuk □ Proses rekrutmen dan kredensial
    □ Proses kredensial ulang
    □ Proses penambahan kewenangan klinis

    DOKTER SPESIALIS ANESTESI


    Tidak
    No Kewenangan klinis Diminta Disetujui disetujui
    M DS TA TK
    1 Management of conditions requiring skills ordinarily acquired during
    post internship specialty training including non-anesthesiology training
    or as a result of documented experience. Privileges include the
    provision of local infiltration anesthesia; topical application and minor
    nerve blocks; patient- controlled analgesia and IV sedation in a manner
    which does not cause loss of protective reflexes.
    2 Management of procedures for rendering a patient insensible to pain and
    emotional stress during surgical, obstetrical and certain medical
    procedures; the support of life functions under stress of anesthetic and
    surgical manipulations; the clinical management of the patient
    unconscious from whatever cause; spinal anesthesia (“Saddle Block”);
    epidural anesthesia; plexus anesthesia; Intravenous regional anesthesia
    (“Bier-Block”); IV sedation in a manner that may cause loss of
    protective reflexes; and the management of problems in pain relief by
    regional anesthetic techniques.
    3 Management of problems in pain relief; the management of problems in
    cardiac and respiratory resuscitation; the management of specific
    methods of respiratory therapy and the clinical management of various
    fluids, electrolyte and metabolic disturbances.
    4 The Clinical Management of patients in chronic pain including
    evaluation, diagnostic work-up, development of a treatment plan,
    follow-up care and referrals as necessary. Treatment modalities include
    medication management and procedures such as: epidural steroid
    injections, caudal injections, peripheral and sympathetic nerve blocks,
    selective nerve root blocks, trigger point injections, facet nerve
    (cervical, thoracic, lumbar) blocks, intrathecal infusion pump trials
    including placement and refills, discograms, IDET procedures,
    rhizotomy procedures, spinal cord stimulator trials and implantations,
    percutaneous disc decompressions, vertebroplasties, and epidural blood
    patch.
    5 Others :

    Keterangan :
    - M : mandiri - DS : dibawah supervisi
    - TA : tak ada alat - TK : tak ada kompetensi

    No.Form : F.KM.2
    Hal 1 dari 2
    Revisi 00
    KOMENTAR Tanda tangan Tanggal
    (dokter pemohon) (dokter pemohon)

    DISETUJUI sebagaimana permintaan


    DISETUJUI dengan modifikasi (lihat bawah)
    DITOLAK (lihat bawah)
    KOMENTAR
    (Komite Medik)

    Nama (KOMITE MEDIK) Tanda tangan Tanggal

    Petunjuk :

    DOKTER PEMOHON :

    1. Pemohon harus memiliki “KOMPETENSI PENUH” untuk setiap kompetensi klinik yang
    dimintakan.
    2. “Kompetensi penuh” artinya : dokter pemohon tidak memerlukan supervisi dalam melakukan
    tindakan klinis.
    3. Dokter pemohon mengisi kolom yang diminta saja, kemudian melengkapi kolom “komentar” dan
    menandatangani .
    4. Tandai dengan tick (√) pada kolom yang bertanda “diminta”, dan tandai dengan cross (X) apabila
    tidak diminta.
    5. Setiap kewenangan klinis yang diminta harus dibuktikan dengan bukti-bukti seperti yang tercantum
    dalam masing-masing kewenangan klinis (bila perlu fotokopi sertifikat kompetensi yang telah
    dilegalisir)

    KOMITE MEDIK :

    1. Memberikan rekomendasi atas “kewenangan klinis” yang diminta oleh dokter pemohon dengan
    memberikan tanda tick (√) pada kolom yang sesuai.
    2. Memberikan komentar dan menandatangani nya.

    No.Form : F.KM.2
    Hal 2 dari 2
    Revisi 00

    You might also like