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180-02 Appointment & Reappointment /AHP
Attachment 4 – Privilege form for NP
UC Davis, Student Health and Counseling Services
NURSE PRACTITIONER
PRIVILEGE DELINEATION FORM
This privilege form describes the qualifications related to competency to exercise the defined clinical privileges that may be
requested by a qualified practitioner based on the training and experience required. Privileges granted may only be exercised at
the site(s) and setting(s) that have the appropriate equipment, staff, and other support required to provide the services defined in
this document. Delegated medical functions may be performed in accordance with written, Standardized Procedures of the
organization as defined by California regulation. The applicant must also adhere to any additional organizational, regulatory, or
accrediting requirements that this facility is obligated to meet. The exercise of these privileges requires a collaborating physician
who must be available onsite in the clinical practice or available by electronic or telephone means as specified in local protocols
and procedures.
Instructions: Please check off the “Requested” box for all privileges requested. If you wish to exclude any procedures,
please strikethrough, initial and date those procedures that you DO NOT wish to request.


Approved
Requeste
d
NAME :
Privileges
Initial Criteria
CORE PRIVILEGES
Core privileges include, but are not limited
to:
Performance of history and physical
examinations.
Development of treatment plans
Ordering of diagnostic tests and therapeutic
modalities such as medications,
treatments, and subspecialty consultations.
Performance of delegated medical
functions as defined by the written
Standardized Procedures for Nurse
Practitioners of the SHS and organizational
policies and procedures.
Educating , counseling, instructing patients
concerning health status, results of tests,
disease process and health maintenance.
Microscopy (skin KOH, vaginal wet prep)
IUD removal
IV Fluid Administration
Destruction of skin lesion
Current, active, unrestricted California
Registered Nurse License; AND
Current, active, unrestricted California
Nurse Practitioner certification; AND
Successful completion of an accredited
Nurse Practitioner program; AND
Current state furnishing number AND
DEA certificate with schedules
lII-V.
Education and training to support setting
and patient population AND
Current BLS
Initial review of 30 medical records which
may be a combination of concurrent and
retrospective chart reviews to be completed
within one month by the proctor and/or peer
review committee. Additional charts may be
required at the discretion of the Medical
Director.
Initial review to be completed within a one
month time interval. If necessary, this
timeline may be extended not to exceed
one month.
SPECIALIZED PRIVILEGES
Criteria
Check privilege being requested:


Repair of superficial cutaneous lacerations
with use of topical or local infiltration
anesthetic administration (excludes
complicated, deep tissue repairs of muscle,
tendon, nerve, blood vessels or other deep
tissue structures)


Incision and drainage of localized
cutaneous abscesses


Dermatologic intralesional injection except
face


Dermatologic intralesional injection of face


Initial management of uncomplicated minor
closed fractures, splint application
(excludes application of circular casting)
 Credentials as outlined above; AND
 Documented training OR 1 peer
reference that attests to current clinical
competency (within the past 3 Years)
in requested special privileges; AND
 Observation of 1 procedure performed
by a qualified proctor*, AND
 Concurrent observation of 3 procedures
with a qualified proctor* present AND
retrospective chart review of 3
procedures until competency is
confirmed.
o For Implanon/Nexplanon removal,
concurrent observation of 1
procedure with a qualified proctor*
present AND retrospective chart
review of 3 procedures until
competency is confirmed.
*Qualified Proctor: SHCS provider
currently privileged for the respective
privilege and approved by the Medical
Director to proctor.
Continued on next page.
Continued on next page.
3/2017
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Renewal Criteria
Core privileges are renewed with
reappointment.
Maintenance of active, unrestricted California
licensure, and other licensure/practice
requirements as defined in the initial
application; AND
Current demonstrated competency as
evidenced by satisfactory quality/peer review
of a minimum of 15 medical records/3 year
reappointment period.
Demonstrated ability to work well with patients
and staff as reflected in the periodic
performance evaluation.
Annual competency testing for
Microscopy (skin KOH, vaginal wet prep)
Renewal Criteria
Meet the requirements listed above
AND for Specialized Privileges:
Must have successfully performed at least 5
procedures in the past three (3) years or
certification of competency by Medical
Director to maintain this privilege.
Continued on next page.
180-02 Appointment & Reappointment /AHP
Attachment 4 – Privilege form for NP
UC Davis, Student Health and Counseling Services
NURSE PRACTITIONER
SPECIALIZED PRIVILEGES (continued)


Nail excision


Removal of foreign body, subcutaneous,
simple


IUD Insertion


Implanon/Nexplanon Insertion

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Implanon/Nexplanon removal*


Cyst and soft tissue injection


Bartholin Cyst Incision & Drainage
including placement of WORD catheter


Shave / Punch Biopsy


Local Anesthesia

Digital block

Topical
_________
OTHER - SPECIFY
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PRIVILEGE DELINEATION FORM
Criteria (continued)
Renewal Criteria
OR, If currently privileged for the identified
special privilege at UCDHS or at an
acceptable institution (acceptable per
medical director), completion of 1 observed
procedure by qualified proctor*, AND 1
concurrent proctoring by qualified proctor*
until competency is confirmed for the
special privilege requested.
Meet the requirements listed above
AND for Specialized Privileges:
Must have successfully performed at least 5
procedures in the past three (3) years or
certification of competency by Medical
Director to maintain this privilege.
NOTE: Individuals who do not meet the
above initial criteria for the special
privilege being requested may be
considered on a case-by-case basis
upon evaluation by Medical Director in
consultation with Peer Review Chair and
a qualified physician proctor* with the
current privilege.
*Qualified Proctor: SHCS provider currently
privileged for the respective privilege and
approved by the Medical Director to
proctor.
I certify that I have had the necessary training and experience to perform the procedures that I have requested.
The burden of producing information deemed adequate by the organization for a proper evaluation of current
competence, current clinical activity and other qualifications and for resolving any doubts related to
qualifications for the requested privileges is mine. I have reviewed all the criteria that pertain to those privileges
that I am requesting and I certify that I meet those criteria.
In exercising the privileges granted to me, I agree to strictly abide by the facility’s Credentialing Policies and
Procedures. I acknowledge that any restrictions on the clinical privileges granted to me are waived in an
emergency/disaster situation involving threat to patient life, recognizing that immediately upon stabilization of
the patient, I shall obtain the services of an appropriately credentialed and privileged practitioner to care for the
patient.
Applicant’s Name (Print)
Signature /Date
I have reviewed the applicant’s credentials, experience, training, health status, current competence and peer
recommendations relative to this request for privileges. The following recommendations are made:
RECOMMENDATIONS/APPROVAL
Supervisor___________________
Date ___/____/____

Recommended
_______________
Date ___/____/____

Recommended
Peer Review Chair_______________
Date ___/____/____

Recommended
Medical Director
Executive Director _________________ Date ___/____/____

APPROVED DENIED  DEFERRED
Privileges Effective: From ___/____/____ to ___/____/____ (not to exceed appointment date)
3/2017
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