Privileging - Nurse, Medical Assistant
Name
Date
-
Month
-
Day
Year
Date
Check the boxes next to the privileges you seek.
Nebulizer
Meter-dose inhalers
Pulse Ox
Peak Flow
Blood Pressure
Tympanogram
Ear Irrigation
Injections (drawing and injection)
Suture removal
Autoclave
Glucometer demonstration
PPD
Hep B
EPSDT
Immunizations
Establish IV access
Administer medications per IV
EKG Spirometry
AED
O2
Strep
Mono
H-Pylori
Flu
U/A
UCG
Glucose
Sed Rate
A1c
Hemoglobin
Pap forms
Occult blood
Phlebotomy
Specimens for transport
Wet prep
KOH
Urine Micro
CBC
Medical translation (enter language)
Concerns/comments:
I attest that I have appropriate training, competence, experience,and comfort level for each privilege requested:
Date
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: