Minden Medical Center
Surgical Assistant
Delineation of Privileges
NAME:__________________________________
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Initial Appointment
DATE: _____________________________
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Reappointment
Staff Category: Allied Health Professional
Applicant: Check off the “Requested” box for each privilege requested. Applicants have
the burden of producing information deemed adequate by the Hospital for a proper
evaluation of current competence, current clinical activity, and other qualifications and for
resolving any doubts related to qualifications for requested privileges. Please strike
through any privileges you do not wish to request.
Other Requirements
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Note that privileges granted may only be exercised at the site(s) and setting(s) that
have the appropriate equipment, license, beds, staff, and other support required to
provide the services defined in this document. Site-specific services may be defined
in hospital or department policy.
This document is focused on defining qualifications related to competency to
exercise clinical privileges. The applicant must also adhere to any additional
organizational, regulatory, or accreditation requirements that the organizations
obligated to meet.
Criteria for Appointment:
1. Successful completion of an approved surgical technologist or surgical first assistant
education program by an appropriate accrediting body 2. Current certification as a
certified surgical technologist/certified first assistant (CST/CFA) 3. Current licensure to
practice as a surgical technologist issues by the state regulatory authority or board of
medicine (if applicable) 4. Employment by or an agreement with a physician on the active
medical staff with surgical clinical privileges as supervising physician. Functions under the
direct supervision of the sponsoring physician 5. Shall adhere to all Medical Staff Bylaws,
Rules & Regulations. Failure to comply may result in withdrawal or modification of
privileges Surgical Assistant and sponsoring physician.
Medical Record Charting Responsibilities
Each direct patient care service provided by the surgical assistant (SA) must be documented as
such in the patient’s medical record either by the supervising physician or by the SA. All entries
by the SA must be countersigned by the supervising physician within 24 hours. Under no
circumstances may the SA write or dictate the operative note or report or the discharge
summary.
Supervision
All practice is performed under the supervision of the designated physician(s) and in accordance
with written policies and protocols developed and approved by the department of surgery, the
medical executive committee and the governing board. The supervising physician must be
Surgical Assistant Privileges
Staff Use: Effective from ____/____/____ to ____/____/____
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Minden Medical Center
Surgical Assistant
Delineation of Privileges
present in the same room if logically required by the nature of the particular service or if so
specified in the grant of services to the surgical assistant. Otherwise, must be immediately
available by telephone or on hospital premises if required for consultation.
Surgical First Assistant
The surgical first assistant is a trained individual who is capable of participating in operations and
actively assisting the surgeon as part of a good working team, according the American College of
Surgeons. Additionally, the surgical first assistant provides aid in exposure, hemostasis, and other
technical functions, thereby helping the surgeon carry out a safe operation with optimal results for the
patient.
Surgical First Assistant Duties include:
 Position the patient
 Provide visualization of the operative site by appropriate placement and securing of retractors
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with or without padding; packing with sponges; digital manipulation of tissue, suctioning,
irrigating, or sponging; manipulation of suture materials (e.g., loops, tags, running sutures);
proper use of body mechanics to prevent obstruction of the surgeon’s view
Utilize appropriate techniques to assist with hemostasis
Participate in volume replacement or autotransfusion techniques as appropriate
Select and apply appropriate wound dressings, including liquid or spray occlusive materials,
absorbent material affixed with tape or circumferential wrapping, immobilizing dressing (soft or
rigid)
Provide assistance in securing drainage systems to tissue
Holds retractors or instruments as directed by the surgeon
Sponges or suctions operative site
Applies electrocautery to clamps on bleeders
Cuts suture material as directed by the surgeon
Connects drains to suction apparatus
Applies dressings to the closed wound
Scrub Surgical Technologist
The scrub surgical technologist handles the instruments, supplies, and equipment necessary during the
surgical procedure. S/he has an understanding of the procedure being performed and anticipates the
needs of the surgeon. S/he has the necessary knowledge and ability to ensure good quality patient care
during the operative procedure and is constantly on vigil for maintenance of the sterile field.
Scrub Surgical Tech Duties include:
 Check supplies and equipment needed for surgical procedure
 Scrubs, gowns, and gloves
 Sets up sterile table with instruments, supplies, equipment, and medical/solutions needed for
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procedure
Gowns and gloves for surgeon and assistants
Surgical Assistant Privileges
Staff Use: Effective from ____/____/____ to ____/____/____
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Surgical Assistant
Delineation of Privileges
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Assists in draping sterile field
Passes instruments and other appropriate items to surgeon and assistants during procedure
Maintains highest standard of sterile
Cleans and prepares instruments for terminal sterilization
Assists other members of team with terminal cleaning of room
Assists in preparing room for next patient
Requested _____ Granted _____
On Nursing Unit
 Accompanies physician on rounds
 Remove sutures as required by physician
 Make entries on Progress Notes, date/time/signs appropriately
 Participates in patient education and discharge planning
 Assist physician during treatment and examination of patient
Requested _____ Granted _____
Special/Other Privileges
Special/Other privileges requested for which you have current clinical competency may be listed
below. Documentation of training and/or experience must be provided for any privileges
requested. I understand that by making this request, I am bound by the applicable laws and
policies of Minden Medical Center and hereby stipulate that I meet the minimum threshold
criteria for this request.
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__________________________________
Requested_____ Granted______
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__________________________________
Requested_____ Granted______
Acknowledgement of Practitioner
I hereby certify that I possess the education, training, current experience and demonstrated
performance to justify granting of clinical privileges in those areas requested. I understand that
in making this request, I am bound by the applicable bylaws and policies of the hospital and
hereby stipulate that I meet the threshold criteria for each request.
_____________________________
Applicant Signature
_______________
Date
Surgical Assistant Privileges
Staff Use: Effective from ____/____/____ to ____/____/____
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Surgical Assistant
Delineation of Privileges
SPONSORING PHYSICIAN’S STATEMENT
The applicant is my employee, and I agree to sponsor this applicant’s request for the
requested privileges specified above. As the Supervising Physician, I will participate as
requested in the evaluation of competency (i.e., at the time of reappointment and, as
applicable, at intervals between reappointment, as necessary) and further agree that the
supervised practitioner will not exceed the scope of practice defined by law (within his or
her licensing agreement—i.e., supervising/collaborating agreement)I know this individual
to be both qualified and competent to perform all requested privileges and further accept
responsibility for the actions of this individual in the Hospital.
Sponsoring Physician’s Printed Name
Date
Sponsoring Physician’s Signature
Date
I have reviewed the requested clinical privileges and supporting documentation for the above
named applicant and recommend the privileges as indicated above.
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Medical Executive Committee
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Date
Approve as recommended by Medical Executive Committee
Deny
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Board of Trustees
_____________________
Date
Surgical Assistant Privileges
Staff Use: Effective from ____/____/____ to ____/____/____
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