Certified Registered Nurse Anesthesis

Transcription

1 Certified Registered urse Anesthesis (CRA) Welcome Thank you for applying to ash Health Care, Inc. Attached please find a copy of our application for you to complete. Please review the instructions and use them as a check off sheet to help with all of the supporting documentation that is needed. If you have any questions you may contact the Medical Staff Office at or via atjapinyan@nhcs.org. Please return your completed application to: ash Health Care Systems, Inc. Medical Staff Services 2460 Curtis Ellis Drive Rocky Mount, C Please remember to include all supporting documents with the application. An incomplete application can delay the credentialing process. After your application has been received in the medical staff office, it will be reviewed by the medical director. Upon approval you will receive notification and information regarding orientation. Sincerely, Jennifer Jennifer A. Pinyan, RHIT Medical Staff Coordinator (office) (fax) japinyan@nhcs.org Medical Staff Application - CRA Page 1

2 Certified Registered urse Anesthesis CRA TABLE OF COTETS I. ISTURCTIO SHEET II. MEDICAL STAFF APPLICATIO III. PRIVILEGES Medical Staff Application - CRA Page 2

3 ISTRUCTIOS Before submitting the Application, make sure you have: Included an answer in all spaces. Indicate /A, if the question is not applicable. Sign and date privilege form(s). Signed and dated the last page of the Application. Before submitting the Application, make sure you have enclosed the following, if applicable: Copy of the provider s original state(s) license(s) and current registration. Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider(s) covered coverage amounts, effective date, expiration date, and policy number. Minimum limits of $1,000,000 and $3,000,000. (unless covered through hospital policy) Copy of PI verification letter Copy of AAA certification/recertification. Copy of verification of certification/recertification by the CBO Copy of ACLS/PALS certification Current PPD/TB skin results. Copy of diploma from anesthesia training program Copy of Curriculum Vitae (CV) or work history after graduation Provide a listing of CME s obtained within the last 2 years. Copy of driver s license Medical Staff Application - CRA Page 3

4 Medical Staff Application A. DEMOGRAPHIC AD PERSOAL DATA: ame of Applicant: Last ame First ame Middle ame Maiden Home Address Street City Zip Home Telephone #: Pager #: Mobile #: Date of Birth: / / Place of Birth: Social Security umber: - - Sex: Language(s) spoken, including sign language: Personal Information: Marital Status: Married Single Divorced If married, please provide ame of Spouse: Type of Appointment Requested: CRA Full time CRA Part time CRA - PR When would you desire to begin work? ame of Practice/Group: ash Health Care Anesthesiology Department =============================================================================================== PI umber Medicare/Medicaid umber / License umber Exp. Date (Attach copy to application) AAA umber Exp. Date (Attach copy to application) Medical Staff Application - CRA Page 4

5 A. DEMOGRAPHIC AD PERSOAL DATA (Continued) Provide the following information for each state in which you are currently or were previously licensed to practice (If not enough space please attach additional sheet): STATE DATE OF LICESE LICESE UMBER STATUS: Active,Inactive,Suspended EXPIRATIO DATE / / / / / / / / PLEASE ATTACH A COP OF EACH STATE LICESE CERTIFICATE List all hospitals where you currently have privileges and indicate the type and status of those privileges: (Type: active, admitting, associate, consulting, courtesy. Status: pending, provisional, suspended, temporary, visiting) Hospital Department and Status of Privilege Dates of Affiliation (Primary admitting facility) B. EDUCATIO AD PRACTICE HISTOR Professional School Attended: Institution Address City State Zip Degree From / / To / / Internship: Institution Address City State Zip Specialty From / / To / / Residency: Institution Address City State Zip Specialty From / / To / / Medical Staff Application - CRA Page 5

6 B. EDUCATIO AD WORK HISTOR - (Continued) Other Residency/Fellowship - (specify) Institution Address City State Zip Specialty From / / To / / During your internship, residency, fellowship or teaching appointment: a. Where you ever disciplined, suspended, place upon probation, formally reprimanded, or asked to resign? ES O b. Did you have an interruption in your training for 30 or more consecutive days? ES O List work history since beginning of professional school; please be specific. (If not enough space, please attach additional sheet) Current practice Previous practice Previous practice Previous practice Previous practice FROM / TO / / (Month / ear) (Month / ear) / / (Month / ear) (Month / ear) / / (Month / ear) (Month / ear) / / (Month / ear) (Month / ear) / / (Month / ear) (Month / ear) List other training and/or education within the last three years, if applicable. Have you ever been involved in a malpractice claim or lawsuit? (This includes claims, lawsuits, and settlements in or out of court, and arbitration or medication proceedings, in any state.) Claimant s name: Age: Date of Loss: Insurance defending you: Was lawsuit filed? If yes, when (month/year): Status: Open Closed Dismissed Settled Trial Amount of Payment: Was payment a settlement or award of damage? Allegations: Description of treatment: Medical Staff Application - CRA Page 6

7 C. PROFESSIOAL IFORMATIO Please circle yes or no for the following questions. Please provide details on the attached Supplemental Form for any questions to which you answer yes. ES O 1. Has your employment, medical staff appointment, or clinical privileges every been voluntarily or involuntarily suspended, diminished, revoked, refused, relinquished, or limited at any hospital or other health care facility? 2. Have you ever withdrawn your application for appointment or reappointment or resigned from the medical staff before a decision was made by the hospital or governing board? 3. Have you ever been suspended, sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance program (Medicare, Medicaid, BCBS 4. Have you ever been the subject of an investigation by any private, federal or state agency concerning your participation in any private, federal or state health insurance program? 5. Have you ever been subject to probationary conditions or have proceedings to those ends ever been instituted or recommended by a committee or governing body of any hospital, health care institution or P.R.O? 6. Has your request for any specific clinical privilege(s) been denied or granted with limitations (aside from ordinary requirements of proctorship) or has such a denial or limitation ever been recommended by a committee or governing body? 7. Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings in any professional organization? 8. Has your license to practice your profession in any jurisdiction ever been surrendered, suspended, revoked, denied or subject to probationary conditions? 9. Have you ever been the subject of any licensure authority investigation or disciplinary action in any jurisdiction? 10. Has your Drug Enforcement Agency or other controlled substance authorization ever been suspended, revoked, reduced or not renewed? 11. Have you ever voluntarily relinquished any medical staff membership, clinical privilege(s), medical organization or professional society membership, professional license(s) or narcotics registration? 12. Have you ever been convicted of any misdemeanor other than minor traffic violations, felony or have been named as a defendant in any criminal proceeding 13. Have you ever been treated for alcohol or other substance abuse or do you have a history of drug or alcohol abuse? 14. Has any aspect of your care ever been investigated by another hospital/facility in which you held clinical privileges? 15. Do you presently have a physical or mental health condition that may affect your ability to exercise the clinical privileges requested or would require an accommodation in order for you to exercise the privileges requested safely and competently? A A Medical Staff Application - CRA Page 7

8 SUPPLEMETAL FORM Provider ame: Please explain: Medical Staff Application - CRA Page 8

9 MEDICAL STAFF APPLICATIO PAST AFFILIATIOS Applicant s ame: PAST AFFILIATIOS: List in chronological order all past institutional/practice affiliations since the completion of your postgraduate education. This includes, without limitation, all hospitals, businesses, charitable organizations, educational institutions, corporations, military organizations or government agencies, (please include a copy of orders or discharge papers). Complete addresses must be included. If more space is needed, attach an additional sheet. If the foregoing chronology does not account for all time periods since the completion of your postgraduate education, please describe your whereabouts and/or activities during such periods. Facility/Practice ame: Mailing Address: Type of Privileges: Phone: Fax: Contact ame (if available): Dates of Appointment: From To: Facility/Practice ame: Mailing Address: Type of Privileges: Phone: Fax: Contact ame (if available): Dates of Appointment: From To: Facility/Practice ame: Mailing Address: Type of Privileges: Phone: Fax: Contact ame (if available): Dates of Appointment: From To: Facility/Practice ame: Mailing Address: Type of Privileges: Phone: Fax: Contact ame (if available): Dates of Appointment: From To: Medical Staff Application - CRA Page 9

10 MEDICAL STAFF APPLICATIO REFERECES Applicant s ame: Please refer to the facility specific requirements regarding peer references. List 2 personal and 3 professional references that have current personal knowledge of and can evaluate your current clinical ability, ethical character, health status and ability to work cooperatively with others. The named peer references must have acquired their knowledge through recent observation of your professional practice over a reasonable period of time. one of the peer references should be related to you by family. A confidential questionnaire will be sent to these individuals. PERSOAL ame: Title: Group/Practice or Affiliation ame: Dates of Association through PO Box Street City State Zip Telephone: Fax: ame: Title: Group/Practice or Affiliation ame: Dates of Association through PO Box Street City State Zip Telephone: Fax: PROFESSIOAL ame: Title: Group/Practice or Affiliation ame: Dates of Association through PO Box Street City State Zip Telephone: Fax: ame: Title: Group/Practice or Affiliation ame: Dates of Association through PO Box Street City State Zip Telephone: Fax: ame: Title: Group/Practice or Affiliation ame: Dates of Association through PO Box Street City State Zip Telephone: Fax: Medical Staff Application - CRA Page 10

11 MEDICAL STAFF APPLICATIO Applicant s ame: Facility ame: Acknowledgements and Release I fully understand that any significant misstatements in or omissions from this application constitute cause for denial of appointment or cause for summary dismissal from the medical staff. All information submitted by me in this application is current and true to my best knowledge and belief. In making this application for privileges and appointment to the medical staff of this facility, I acknowledge that I have received and read the Bylaws, Rules and Regulations of the medical staff of this facility, and that I am familiar with the principles, standards and ethics of The Joint Commission Accreditation of Healthcare Organizations and the national, state and local associations that apply to and govern my specialty and/or profession. I agree to be bound by the terms thereof if I am granted membership or clinical privileges, and I further agree to be bound by the terms thereof without regard to whether or not I am granted membership or clinical privileges in all matters relating to the consideration of my application for appointment to the medical staff. I acknowledge that the provisions of said Medical Staff Bylaws relating to confidentiality and release from liability are express conditions to my application for, and acceptance of, Medical Staff membership and the continuation of such membership and to my exercise of clinical privileges. I further agree and abide by such facility and staff policies and staff rules and regulations as may be from time to time enacted. I agree to maintain the confidentiality of all patient information, peer review information and all other information to which I have access. I further agree to provide treatment and continuous care and supervision of patients for whom I have responsibility, and timely adequate completion of record documentation. By applying for appointment to the medical staff, I hereby signify my willingness to be interviewed in regard to my application and authorize the facility, its medical staff and their representatives/designees to consult with administrators and members of the medical staffs of other facilities or institutions with which I have been associated and with others (including past and present malpractice carriers) who may have information bearing on my professional competence, character and ethical qualifications. I hereby further consent to the inspection by the facility, its medical staff and its representatives/designees of all records and documents that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested, as well as my moral and ethical qualifications for staff membership. I hereby release from liability all representatives/designees of the facility and its medical staff for their acts performed in good faith and without malice in connection with evaluating my application, credentials and qualifications. I further hereby release from liability any and all individuals and organizations that provide information to the facility or its medical staff, in good faith and without malice, concerning my professional competence, ethics, character, personal health information and other qualifications for staff appointment and clinical privileges. I hereby consent to the release of such information. I hereby further authorize and consent to the release of information by this facility or its medical staff/designees to other facilities, medical associations and other interested persons on request regarding any information the facility and the medical staff may have concerning me as long as such release of information is done in good faith and without malice, and I hereby release from liability this facility and its staff and/or designees for so doing. I understand and agree that I, as an applicant for medical staff membership, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, personal health information and other qualifications and for resolving any questions about such qualifications. I have not requested privileges for any procedures for which I am not qualified. Furthermore, I realize that certification by a board does not necessarily qualify me to perform certain procedures. However, I believe that I am qualified to perform all procedures/privileges I have requested. Date Signature The facility will treat this application and any information secured in connection therewith in strict confidence and will employ all reasonable safeguards to protect the Applicant s privacy. Medical Staff Application - CRA Page 11

12 Privilege Request Certified Registered urse Anesthetist ame: Initial Appointment Reappointment Check area of coverage: Labor & Delivery GH/DH Qualifications: Graduate of approved nursing program with a Bachelor of Science in ursing or another appropriate baccalaureate degree from an approved nursing program Graduate from a nurse anesthesia educational program accredited by the AAA Council on Accreditation of urse Anesthesia Educational programs. Recognized by the AAA Council for Certification in urse Anesthetists with verification of certification/recertification by the CBO. Current licensure to practice as a Registered urse in orth Carolina Professional liability insurance coverage issued by employer or recognized company and in an amount equal to or greater than the limits established by the governing board BCLS Certification, recertification required every 2 years ACLS Certification; recertification required every 2 years RP Certification; recertification required every 2 years (For L & D) Demonstrate the ability to understand, communicate and react effectively and appropriately to the needs of surgical or obstetric (For L & D) patients. Be able to demonstrate clinical competence per the job s Skills Checklist before being allowed to perform independently. Experience: CRAs with required credentials are eligible to apply. Evidence of current experience will be reviewed. Reappointment requirements: Current demonstrated competence and an adequate volume to consist of a minimum of 850 hours of practice over a two year recertification period. Medical Staff Application - CRA Page 12

13 Privilege Request Certified Registered urse Anesthetist Page 2 ame: Initial Appointment Reappointment Scope of Practice for CRA Performing and documenting a pre-anesthetic assessment and evaluation of the patient. Administering the anesthetics, adjuvant drugs, accessory drugs and fluids necessary to induce and manage the anesthetic, to maintain the patient s physiologic homeostasis, and to correct abnormal responses to the anesthesia or surgery Applying or inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient s physical status Managing a patient s airway and pulmonary status using current practice modalities Managing emergence and recovery from anesthesia with medications, fluids, or ventilator support in order to maintain homeostasis; to provide relief from pain and anesthesia side effects; or to prevent or manage complications Releasing or discharging patients from the post-anesthesia care area and providing post-anesthesia follow-up evaluation and care Implementing acute pain management modalities Respond to emergency situations as needed Clinical education of student register nurse anesthetists (SRAs) who are enrolled in a nurse anesthesia educational program accredited by the Council on Accreditation of urse Anesthesia Educational Programs (COA). CRA Privileges Pre-anesthetic assessment Requesting laboratory/diagnostic studies Pre-anesthetic medication General anesthesia and adjuvant drugs Regional anesthesia techniques -Epidural (For L & D) -Local infiltration -Bier Block -Topical Sedation techniques Cardiopulmonary resuscitation management Invasive and noninvasive monitoring Airway management techniques Mechanical ventilation/oxygen therapy Fluid, electrolyte, acid-base management Blood, blood products, plasma expanders Peripheral intravenous/arterial catheter placement Acute pain therapy Post-anesthesia care/discharge External Jugular Vein catheter placement Medical Staff Application - CRA Page 13

14 Privilege Request Certified Registered urse Anesthetist Page 3 Other CRAs are supervised by a physician. Clinical Ongoing Performance review is completed by Anesthesiology with appointment/reappointment applications reviewed by the Department Chairman. Written evaluations of the CRAs performance are to be submitted to the Medical Staff office. Acknowledgement of practitioner I have requested only those services for which, by education, training, current experience, and demonstrated performance, I am qualified to perform and which I wish to exercise at ash Health Care Systems, Inc. I understand that, in exercising any specific services granted and in carrying out the responsibilities assigned to me, I am constrained by any hospital and medical staff policies and rules applicable generally and any applicable to the particular situation. Any restriction on the specified services granted to me is waived in an emergency situation, and in such situation, my actions are governed by the applicable section of the policies governing allied health professionals. Signed: Date: Medical Staff Application - CRA Page 14