Application For Appointment Credentialing And Clinical-Books Pdf

Application for Appointment Credentialing and Clinical
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2 Application for Clinical Privileges,Introduction. The purpose of delineating the privileges of medical staff is to ensure a high standard. of patient care by matching the work that a practitioner wishes to perform with. demonstrated skill and competence in a hospital with the delineated role of the. Below are suggested privileges considered appropriate for general practice. It is understood that training and experience can vary considerably and any general. practitioner who feels that relevant experience equips him or her to undertake. procedures not listed should enter these in the space provided and describe briefly. their special training in these areas, The Credentials Committee will consider all of the clinical privileges requested in your. application The clinical privileges granted will take into consideration the delineated. role of the hospital or service and its support capabilities. Previous clinical privileges denied, a Have you ever been denied a defined scope of clinical practice Yes No. b Has your right to practise ever been withdrawn suspended terminated. or reduced, If you answered YES to either of the above questions please provide full details. Please attach any supporting documentation or data that will assist the. Credentials Committee to consider your application. Outline nature of clinical privileges sought may be more than one. GP anaesthesia GP obstetrics,GP emergency medicine GP orthopaedics.
GP general surgery GP paediatrics,GP medical Other. GP mental health, Details are to be specified on following pages where relevant Please note that the. Position Description specifies the clinical and other duties expected of all General. Practitioner Visiting Medical Officers For example this could be. 1 Participate in the one in ten 24 hour Doctor of the Day general practitioner. roster to provide, Medical services to patients of the Emergency Department. After hours on call to all admitted patients of the hospital and. Admission and ongoing care of patients, Application Form General Practitioner Page 2 of 14. 2 Provide medical services to patients who are admitted under the GP Visiting. Medical Officer, 3 Participate in multi disciplinary case conferences.
Please list the Facility or Facilities for which you are applying. Facility Name Provider Number,Facility 2,Facility 3. Facility 4,Facility 5,Anaesthesia, Other than for local anaesthesia specific clinical privileges in this area must be. requested If requested clinical duties will involve the administration of anaesthetics. to low risk patients, Subject to the role delineation of the hospital and experience new applicants should be able to demonstrate. completion of a training program for anaesthesia consistent with the Australian and New Zealand College of. Anaesthetist guidelines for general practice anaesthesia Applicants for reappointment will be required to demonstrate. their compliance with the guidelines regarding caseloads and continuing medical education activities. If privileges are requested in this area please indicate below and support the. application with evidence of your experience and training. Clinical Privileges Sought,Emergency Medicine, Subject to the role delineation of the hospital and experience a general practitioner may. Manage patients with minor injuries and ailments and. Provide resuscitation and stabilisation of patients prior to their transfer to. higher levels of care, If further privileges are sought in emergency medicine please indicate below the clinical privileges requested and.
support the application with evidence of your experience and training. Additional Clinical Privileges Sought, Application Form General Practitioner Page 3 of 14. General Surgery, Subject to the role delineation of the hospital and experience a general practitioner may perform minor surgical. procedures, Removal of cutaneous and subcutaneous lesions e g BCCs sebaceous cysts. and lipomata,Drainage of simple abscesses,Surgical treatment of ingrown toenail. If further privileges are sought in general surgery please indicate below the clinical privileges requested and support. the application with evidence of your experience and training. Additional Clinical Privileges Sought,General Medicine.
Subject to the role delineation of the hospital a general practitioner may admit and manage medical inpatients. Patients with a range of acute and chronic health presentations may be admitted to rural hospitals Patients with. serious acute or complex internal medicine problems may be admitted under networked arrangements or in. consultation with an appropriate specialist physician. If further privileges are sought in general medicine please indicate below the clinical privileges requested and support. the application with evidence of your training e g Fellowship in Advanced Rural General Practice Graduate Diploma in. Rural General Practice and experience e g Advanced Rural Skills Post in adult internal medicine. Additional Clinical Privileges Sought,Mental Health. Subject to the role delineation of the hospital and experience a general practitioner may manage inpatients with. mental health conditions that do not need to be in designated or gazetted mental health beds. If further privileges are sought in mental health please indicate below the clinical privileges requested and support the. application with evidence of your experience and training. Additional Clinical Privileges Sought, Application Form General Practitioner Page 4 of 14. Obstetrics, Specific clinical privileges in this area must be requested Subject to the role delineation of the hospital and. experience a general practitioner may, Manage obstetric patients only if they possess a Diploma of Obstetrics or. equivalent and agree to conform to guidelines developed jointly by the. Royal Australian College of General Practitioners RACGP and. Royal Australian New Zealand College of Obstetricians and Gynaecologists. RANZCOG or, Manage obstetric patients as part of shared care arrangements with specialist.
obstetricians, Applicants for reappointment will be required to demonstrate their compliance with these guidelines and continuing. medical education activities If privileges are requested in this area please indicate below and support the application. with evidence of your experience and training,Clinical Privileges Sought. Orthopaedics, Subject to the role delineation of the hospital and experience a general practitioner may manage uncomplicated and. simple fractures, If further privileges are sought in orthopaedics please indicate below the clinical privileges requested and support the. application with evidence of your experience and training. Additional Clinical Privileges Sought,Paediatrics, Subject to the role delineation of the hospital and experience a general practitioner may attend paediatric inpatients in.
accordance with the relevant NCAHS Management of Paediatric Emergency Department Presentations and Admissions. within Paediatric Medical Role Delineation Levels 1 3 Policies Refer NC Area Pol 2945 07 2946 07 and 2947 07. If further privileges are sought in paediatrics please indicate below the clinical privileges requested and support the. application with evidence of your experience and training. Additional Clinical Privileges Sought, Other clinical privileges may be requested e g sexual assault services drug alcohol. services etc, If other clinical privileges are requested please indicate below and support the. application with evidence of your experience and training. Clinical Privileges Sought, Application Form General Practitioner Page 5 of 14. 3 Qualifications Can be detailed in CV, Qualifications University Organisation Year obtained. For applicants who have not held appointments in this health service please provide. certified copies of qualifications or evidence of qualifications obtained. 4 Other training and clinical experience Can be detailed in CV. With respect to your response to Section 2 please provide details of clinical experience and. post qualification training, Include the title of course s undertaken the organisation offering the course and the.
qualification obtained,Clinical Privileges, Privilege Sought Training and Experience Requested. Anaesthesia Yes No,General Surgery,other than minor. surgery listed,General Medicine Yes No,Mental Health Yes No. Obstetrics Yes No,Orthopaedics Yes No,Paediatrics Yes No. Other please list below, Application Form General Practitioner Page 6 of 14.
5 Clinical appointments Can be detailed in CV, Provide details on all current and previous public and private clinical appointments during the. past five years including names of organisations and dates of appointment or other places of. practice for example general practice,Organisation Term of. appointment,Main appointment,Other appointments to. 6 Academic appointments teaching experience Can be detailed in CV. Provide details of current and previous teaching appointments including names of. organisations and dates of appointment,Organisation Status Level Term of. Appointment, Application Form General Practitioner Page 7 of 14.
7 Continuing medical education continuing professional development. a Provide details of your involvement in continuing medical education continuing professional. development Include the name of the college organisation program in which you are. b Please attach current re certification statement or certificate from the relevant college or. advise of CPD activities college based and other undertaken in the last three years. c Have you satisfied the continuing medical education continuing. professional development requirements of your college membership Yes No. fellowship,8 Clinical review peer review, Do you regularly participate in formal quality and peer review activities. Provide details of such quality peer review activities. Application Form General Practitioner Page 8 of 14. 9 Grand rounds health service educational activities. a What educational training activities for junior staff have you participated. in over the past three years, b Are you prepared to conduct a grand round or other educational Yes No. activities for example on a once a year basis, 10 Have you any other information to support this application. 11 Regulatory and indemnity information, a Australia Health Practitioner Regulation Agency Registration number. registration,Is this registration temporary,If yes provide details.
Attach a copy of current Registration Certificate, b Does your registration pertain to an area of Yes No. need If so please detail the type of assessment,process undertaken prior to registration. c Are you registered as a medical practitioner in Yes No. any other country If so please specify, d Do you have any conditions or restrictions placed Yes No. on your registration either in New South Wales or,elsewhere If so please provide full details. e Do you have a medical board appointed Yes No,supervisor If so please provide details including.
name and location of supervisor and frequency of,supervision. f In the past have you ever had any conditions or Yes No. restrictions placed on your registration either in New. South Wales or elsewhere If so please provide full. g Current medical indemnity cover if applicable Expiry date of current policy. Attach a copy of current policy renewal certificate. h Is your proposed clinical privileges reflected in or Yes No N A only if covered. covered by your current medical indemnity by TMF, Application Form General Practitioner Page 9 of 14. i Over the past 10 years has there been or are Yes No. there currently pending any claims settlements or,judgments against you. j Has your current or any previous medical defence Yes No. organisation insurer ever excluded or reduced any,specific area of practice or terminated or denied. k If the answer to either of the above two,questions is YES please provide a detailed.
explanation and specify the name of the relevant,medical defence organisation insurer. l Is your Provider Number subject to any, restrictions Provider Number to be recorded in Yes No. section 2 b,If YES please provide full details,m Do you have a Prescriber Number Yes No. Prescriber Number,If YES is it subject to any restrictions Yes No. If restrictions apply please provide full details,12 Health status.
Do you have a disability health issue that, may impact on your ability to perform any of the cognitive and. physical functions which would fall within the scope of practice that. you are seeking in this application, may require special equipment facilities or work practices to enable. you to perform any aspect of the scope of practice you are seeking. in this application or, might be relevant to determining your scope of practice. If yes please provide details of the disability health issue its impact on your ability to carry. out the scope of practice sought and details of any special equipment facilities or work. practices required, This information can be provided on this form or if you prefer you can provide the. information in a sealed envelope marked CONFIDENTIAL for Director of Medical Services. ONLY appended to this application and indicate here that additional information is provided. Additional Clinical Privileges Sought General Medicine Subject to the role delineation of the hospital a general practitioner may admit and manage medical inpatients Patients with a range of acute and chronic health presentations may be admitted to rural hospitals Patients with serious acute or complex internal medicine problems may be admitted under networked arrangements or in

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