General Practitioner & Emergency Medicine

Privilege Check List

Nama
Alamat

No. Telepon

SERTIFIKAT (Dokter Umum, Spesialis dan lainnya)

Tanggal Lulus

Nama Instansi Pendidikan

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TRAINING & COURSES

Tanggal Pelatihan

Judul Pelatihan

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Saya menyatakan bahwa saya kompeten untuk menangani kasus-kasus yang sesuai
dengan bidang saya.
Saya juga menyatakan kompeten untuk melakukan prosedur teknis seperti terlampir
sebagai bagian dari kewenangan klinis (clinical priveleges).

Tanggal : ________________________

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Tanda tangan dan nama jelas
(Berikan tanda V pada kolom Privilege Desired bila anda memiliki kompetensi tersebut)

Privileges
Privileg
e
Desired

Chairma
n
Approval
Airway Techniques
1. Cricothyrotomy
2. Endotracheal Tube
Anesthesia
1.

Local anesthesia

2.

Simple Regional nerve block

Cardiac Procedures
1.

Cardiopulmonary Resuscitation

2.

Cardioversion/DC Shock

Diagnostic Procedures
1. Arthrocentesis
2. Lumbar puncture
3. Nasogastric/ oral gastric tube (NGT)
4. Pericardiocentesis
5. Proctoscopy
6. Thoracentesis
7. Tonometry
8. Slit lamp exam
Genitourinary Techniques
1. Bladder catheterization
Foley catheters
Suprapubic catheterization
2. Precipitous delivery of newborn
Head / Neck
1. Epistaxis control
2. Laryngoscopy

Privileges
Privilege
Desired

Chairman
Approval
Hemodynamic Techniques
1. Central venous access
Jugular
Peripheral venous access (venous cut down)
2. Intravenous infusion
Orthopedic Procedures
1. Fracture / dislocation
Immobilization
Closed reduction
2. Spine
Cervical immobilization
3. Nail Extraction
Thoracic Procedures
1. Needle thoracostomy
2. Tube thoracostomy
3. Pericardiocentesis
Other Techniques
1. Foreign body removal
2. Gastric lavage
3. Incision and drainage
4. Wound management / suture techniques

Peer Group

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