Privileging - Primary Care Physician and Nurse Practitioner
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Check the boxes next to the privileges you seek.
History and Physical Examination
Well-child care newborn to 6 mos
Well-child 6 mos to 2 years
Outpatient illnesses and disorders of childhood
Outpatient illnesses and disorders of adolescence
Management of immunizations
Uncomplicated prenatal care to 28 weeks
Threatened abortion
Pyelonephritis and other UTI's in pregnancy
Well-woman exams
Diagnosis and treatment of STDs
Contraceptive management
Uncomplicated neurological problem
Uncomplicated musculoskeletal problems
Uncomplicated dermatologic problems
Diabetes management
Hypertensive management
Hyperlipidemia management
CLRD management
Office ENT problems
Uncomplicated ophthalmologic problems such as conjunctivitis, hardiolum, and chalazion treatment
Management of uncomplicated depression/generalized anxiety disorder
Management of ADD/ADHD
Substance abuse diagnosis
Basic life support
Advanced cardiac life support
Automated external defibrillator
Punch biopsy
Uncomplicated excision/biopsy of non-facial skin lesions
Simple laceration repair
Simple abscess incision and drainage
Removal of nasal foreign body
Removal of non-penetrating ocular foreign body
Removal of otic foreign body
Removal of simple skin foreign body
Joint aspiration/injection
Tendon/trigger point injection
Closed reduction of simple fractures and dislocation
Ingrown toenail/toenail removal
Pap smears
Repair of skin lacerations involving more than one layer of closure
Biopsy of simple facial lesions
Colposcopy
Endometrial biopsy
Vaginal diaphragm fitting
Intrauterine device insertion/removal
Cervical biopsy
Sigmoidoscopy
Breast mass aspiration
Acupuncture
Spinal Manipulation
Prescription of Schedule III-V substances
Prescription of Schedule II substances
Routine inpatient care of newborn
Inpatient care of common pediatric illnesses
Inpatient care of complicated pediatric problems such as serious infections (meningitis, pneumonia), fluid and electrolyte problems, neonatal sepsis, status asthmaticus
Inpatient routine uncomplicated labor
Inpatient uncomplicated adult internal medicine problems not including CCU or ICU care
First assist at major surgical procedures
Medical translation (enter language)
Any additional privileges not listed above?
Any comments or concerns?
I attest that I have appropriate training, competence, experience, and comfort level for each privilege requested:
Today's date
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