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Specialty: Physician Assistant – Emergency Medicine
Delineation of Privileges
Applicant's Name:
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Membership
Required Qualifications
Meet all requirements for Advanced Practice AHP staff membership
Education/Training
Completion of a physician assistant training program accredited by the Accreditation Review
Commission on Education for the Physician Assistant (ARC-PA).
Continuing Education
Applicant must have [#] continuing education credits per year directly related to the privileges
requested (waived for applicants who have completed training during the previous 24 months)
Certification
Current PA-C designation. To attain the PA-C designation, PAs must pass the Physician Assistant
National Certifying Exam (PANCE) administered by the National Commission on Certification of
Physician Assistants.
Clinical Experience (Initial) Applicant must be able to provide documentation of provision of services (# and type of cases)
representative of the scope and complexity of the privileges requested during the previous year
(waived for applicants who completed training within the past year).
Clinical Experience
(Reappointment)
Applicant must have provided (# cases) representative of the scope of privileges requested during
the past 24 months
Additional Qualifications
Applicant must have a contract with [name of organization/group] to provide services in this
specialty
OR
Applicant must be employed by the organization
AND
Applicant must have a supervising physician. The supervising physician must be a member of the
(--Active--) medical staff in good standing in the Department of (--Emergency Medicine--) OR have
privileges in the specialty of (--insert specialty--).
AND
Current ACLS, PALS and ATLS Certification
AND
Current DEA Registration with schedules 2, 2N, 3, 3N, 4 and 5
Published: 11/5/2012 8:30:24 AM
Physician Assistant – Emergency Medicine
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[applicant]
Published: 11/5/2012 8:30:24 AM
Primary Privileges: Physician Assistant – Emergency Medicine
Description: Physician assistants practice medicine with supervision by licensed physicians and are involved in
evaluation, care, stabilization and disposition of patients who present to the emergency department as a result of
illness and injury. PAs serve in many roles in emergency medicine, including patient triage, patient care in the ED,
and selective administrative functions.
Request all privileges listed below.
Request
Uncheck any privileges that you do not want to request
Chief
Approval
Dept
Chair
Approval
Medical Screening – perform a medical screening exam.
Evaluation – gather essential information about patients to elicit a detailed and
accurate history, perform an appropriate physical examination, delineate problems and
record or dictate the history and physical in the patient record.
Diagnostics – perform and/or interpret, common laboratory, radiologic, cardiographic,
and other routine diagnostic procedures used to identify pathophysiologic processes.
Therapeutics – Manage simple conditions produced by infection or trauma, and assist
in the management of more complex illness and injury, and take initiative in performing
evaluative and therapeutic procedures in response to life-threatening situations.
Counseling – instruct and counsel patients regarding mental and physical health,
including but not limited to diet, disease, prevention, treatment and normal
development.
Referral – facilitate the referral of patients to the community’s health and social service
agencies when appropriate. Also refer and communicate with appropriate consultants
in regard to patient management.
Write admission orders as requested by the accepting or admitting physician per
organization policies and procedures.
Administer medications ordered by supervising physician or self in conformance with
organizational policy.
Procedures
Abscess incision and drainage
Administration of medications and injections
Advanced Cardiac Life Support including all procedures
Advanced Pediatric Life Support including all procedures
Advanced Trauma Life Support including all procedures
Anoscopy
Arterial puncture and blood gas sampling
Arthrocentesis
Cast and splint application
Central line placement
Dislocation reduction management
Debridement of burns, abrasions and abscesses
Epistasix management
Extensor tendon repair
Fracture reduction
Foreign body removal: ears, note, rectum, soft tissue, throat, vaginal
Immobilization techniques (spine, long bone, etc.)
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Physician Assistant – Emergency Medicine
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[applicant]
Published: 11/5/2012 8:30:24 AM
Intubation – Endotracheal/nasal
Interosseous needle placement
Laceration repair – simple, intermediate and complex
Local anesthesia
Lumbar puncture
Nail trephination/removal
Nasogastric/Orogastric tube placement, lavage and management
Paracentesis
Perform routine procedures such as injections, immunizations, suturing and wound
care
Slit lamp diagnostic and rust ring removal
Tonometry, ocular
Thoracentesis
Thoracostomy tube insertion
Urethral catheter placement and management
Venous access, peripheral/cutdown
FPPE
Retrospective evaluation of (5) cases of patients seen by the PA in the ED admitted to for inpatient medical care.
Retrospective evaluation of (5) cases of patients seen by the PA in the ED admitted to for inpatient surgical care.
Evaluation from ER Head Nurse/Supervisor.
Evaluation of OPPE data collected for review of competency/performance. Data may include: hours worked in ER;
procedures performed; complications; patient satisfaction results; etc.
Acknowledgment of Applicant
I have requested only those privileges for which by education, training, current experience, and demonstrated competency I am
entitled to perform and that I wish to exercise at Demo Health Services.
I also understand that by making this request, I am bound by the applicable Medical Staff Bylaws and/or policies of Demo Health
Services. I also attest that my professional liability insurance covers the privileges I have requested.
I affirm that I will obtain a consultation with a qualified medical staff member when it is in the best interest of the patient and/or
when my expertise does not meet the clinical needs of the patient.
Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are
governed by the applicable section of the Medical Staff Bylaws or related documents.
Practitioner's Signature
Date
Department Chair Recommendation - Privileges
I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):
Recommend all requested privileges
Do not recommend any of the requested privileges
Recommend privileges with the following conditions/modifications/deletions (listed below)
Published: 11/5/2012 8:30:24 AM
Physician Assistant – Emergency Medicine
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[applicant]
Published: 11/5/2012 8:30:24 AM
Privilege
Condition/Modification/Deletion/Explanation
Department Chair Recommendation - FPPE Requirements
Signature of Chief/Designee
Date
Signature of Department Chair/Designee
Date
Submit
Published: 11/5/2012 8:30:24 AM
Physician Assistant – Emergency Medicine
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