Ntice t Applicant: Applicants have the burden f prducing infrmatin deemed adequate by University f Mississippi Medical Center (UMMC) fr a prper evaluatin f current cmpetence, current clinical activity, and ther qualificatins and fr reslving any dubts related t qualificatins fr requested privileges. Nte that privileges granted may nly be exercised at the site(s) and/r setting(s) that have the apprpriate equipment, license, beds, staff and ther supprt required t prvide the services defined in this dcument. Sitespecific services may be defined in hspital and/r department plicy. This dcument is fcused n defining qualificatins related t cmpetency t exercise clinical privileges. The applicant must als adhere t any additinal gvernance (Medical Staff Bylaws, Rules and Regulatins) rganizatinal, regulatry, r accreditatin requirements that the rganizatin is bligated t meet. QUALIFICATIONS FOR PHYSICIAN ASSISTANT T be eligible t apply fr cre privileges as a Physician Assistant, the initial applicant must meet the fllwing criteria: Educatin: Master s degree r higher in Physician Assistant Studies r equivalent area f study Training: Successful cmpletin f an Accreditatin Review Cmmissin n Educatin fr the Physician Assistant (ARC-PA) (r ne f its predecessrs) accredited Physician Assistant educatin prgram Bard Certificatin: Current certificatin by the Natinal Cmmissin n Certificatin f Physician Assistants (NCCPA); r Currently in the prcess t achieve bard certificatin, in which case the physician assistant must becme certified by the NCCPA within six (6) mnths f cmpletin f frmal training Required Previus Experience: Initial appintment: Demnstratin f the prvisin f care, reflective f the scpe f privileges requested, fr a sufficient vlume f adult and/r pediatric inpatients r utpatients during the past 24 mnths; r Successful cmpletin f an ARC-PA accredited prgram within the past 12 mnths. Reappintment: Current demnstrated cmpetence and a sufficient vlume f experience in adult and/r pediatric inpatients r utpatients, with acceptable results, reflective f the scpe f privileges requested, fr the past 24 mnths based n results f nging prfessinal practice evaluatin and utcmes. Evidence f current ability t perfrm privileges requested is required f all applicants fr renewal f privileges. Page 1 f 5
Check requested privileges belw Otlarynglgy Physician Assistant Cre Privileges and Prcedures DO NOT request privileges yu will nt be perfrming in yur current rle. Please strike thrugh and initial any privilege yu wish t exclude frm thse listed belw. Assess, evaluate, diagnse, treat and prvide cnsultatin t patients f all ages wh present with any symptm, illness, injury r cnditin and prvide services necessary t amelirate minr illnesses and/r injuries (in cnjunctin with supervising physician). Stabilize patients with majr illnesses r injuries and assess all patients t determine if additinal care is necessary. Order and interpret apprpriate diagnstic tests. Perfrm evaluatins. Order apprpriate referrals and cnsultatins. Initiate, change r discntinue medical treatment plan. Prescribe, initiate, and mnitr all medicatins which PAs are authrized t prescribe in Mississippi. Initiate cnsultatin fr and mnitr patients during special tests. The cre privileges in this specialty include the prcedures listed belw. Aspiratin f superficial abscess r cyst Cntrl f epistaxis Crysurgery/cautery fr benign disease Emergent endtracheal intubatin Emergent ventilatr management Fiber ptic endscpic evaluatin f swallwing (FEES) Flexible laryngscpy I & D abscess Insertin and remval f IVs Insertin f indwelling urinary catheters Lcal anesthetic techniques Lumbar puncture Myringtmy with r withut tympanstmy tube placement Nasgastric tube insertin/remval Order rehab services Order respiratry services Paracentesis Perfrm electrcardigram tracing Perfrm histry and physical exam Perfrm simple skin bipsy r excisin Perfrm waived labratry testing nt requiring an instrument, including but nt limited t fecal ccult bld, urine dipstick, and vaginal ph by paper methds Peripheral nerve blcks Phlebtmy Placement f anterir and psterir nasal hemstatic packing Pre and pst-perative management f surgical patients Remve nn-penetrating freign bdy frm the eye, nse, r ear Scar revisin Siallithtmy Skin bipsy Suture uncmplicated laceratins Telehealth Vide strbscpy Wund care (including cleansing and debridement) Page 2 f 5
Check requested privileges belw Nn-Cre Privileges and Prcedures DO NOT request privileges yu will nt be perfrming in yur current rle. Administratin f Sedatin and Analgesia Successful cmpletin f Healthstream mdule: Prcedural Sedatin Credentialing First Assist in Surgery Criteria: Successful cmpletin f frmal training in this prcedure r the applicant must have cmpleted hands-n training in this prcedure under the supervisin f a qualified physician preceptr. Required Previus Experience: Demnstrated current cmpetence and evidence f the perfrmance f a sufficient vlume f prcedures in the past 24 mnths r cmpletin f a preceptrship within the past 12 mnths cnsisting f at least 5 precepted prcedures. Maintenance f Privilege: Demnstrated current cmpetence and evidence f the perfrmance f a sufficient vlume f prcedures in the past 24 mnths based n results f quality assessment/imprvement activities and utcmes. Page 3 f 5
ACKNOWLEDGEMENT OF PRACTITIONER: I have requested nly thse privileges fr which by educatin, training, current experience, and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at University f Mississippi Medical Center, and I understand that: a. In exercising any clinical privileges granted, I am cnstrained by Hspital and Medical Staff plicies and rules applicable generally and any applicable t the particular situatin. b. Any restrictin n the clinical privileges granted t me is waived in an emergency situatin and in such situatin my actins are gverned by the applicable sectin f the Medical Staff Bylaws r related dcuments. Signed PHYSICIAN SUPERVISOR S RECOMMENDATION: I have reviewed and recmmend the abve requested privileges based n the prvider s training and/r backgrund. Signature f Physician Supervisr DIVISION CHIEF S RECOMMENDATION (IF APPLICABLE): I have reviewed the requested clinical privileges and supprting dcumentatin fr the abve-named applicant. T the best f my knwledge, this practitiner s health status is such that he/she may fully perfrm with safety the clinical activities fr which he/she is being recmmended. I make the fllwing recmmendatin(s): Recmmend all requested privileges. Recmmend privileges with the fllwing cnditins/mdificatins: D nt recmmend the fllwing requested privileges: Privilege Cnditin/Mdificatin/Explanatin 1. 2. 3. 4. Ntes Divisin Chief Signature Page 4 f 5
DEPARTMENT CHAIR S RECOMMENDATION (IF APPLICABLE): I have reviewed the requested clinical privileges and supprting dcumentatin fr the abve-named applicant. T the best f my knwledge, this practitiner s health status is such that he/she may fully perfrm with safety the clinical activities fr which he/she is being recmmended. I make the fllwing recmmendatin(s): Recmmend all requested privileges. Recmmend privileges with the fllwing cnditins/mdificatins: D nt recmmend the fllwing requested privileges: Privilege Cnditin/Mdificatin/Explanatin 1. 2. 3. 4. Ntes Department Chair Signature Reviewed (withut revisin): Revised: Page 5 f 5