DEPARTMENT OF EMERGENCY MEDICINE
DELINEATION OF PRIVILEGES PHYSICIAN’S ASSISTANT / NURSE PRACTITIONER
NAME: _____________________________________________________ Date: _______________
ED PAs and NPs need to be ACLS certified. PALS or ATLS is not required, except for Pediatric NPs
who need to be PALS certified.
Not Req.
Req.
PRIVILEGES
Suturing (all except facial sutures)
Digital nerve block
I & D abscess
I & D paronychia
Subungual hematoma drainage
Local wound care/burn care
Review patient records
History and Physical exam, including rectal and pelvic
Gastric lavage
Immobilization & splinting of fractures
Start intravenous infusions
Administer intra-muscular & subcutaneous injections
Insert catheters
Pass nasogastric tube
Draw blood/venous & arterial puncture
Perform CPR/BCLS Protocol
Perform ACLS Protocol (requires ACLS certification)
Anterior nasal packing
Eye care/tonometry, flourescein stains
Ear care/removal of impacted cerumen
Assist in other procedures as requested by a physician
Order laboratory & diagnosis testing, which must be countersigned by a licensed physician
within 24 hours.
Participate in departmental rounds & conferences as requested by Director of Service.
Prescribe drugs, which must be countersigned before discharge from Emergency
Department by a licensed physician.
SPECIAL CATEGORY II
Facial suturing (requires 6 month proctoring)
Eye Care/use of slit lamp, foreign body removal
Eye Care/foreign body removal
Tube Thoracostomy
I have requested only those privileges for which by education, training, current experience, and demonstrated
performance I am qualified to perform and that I wish to exercise at the Broadway Campus Hospital. I will
perform only those privileges that are outlined above and that have been agreed upon between my
supervising physician and me.
Applicant’s Signature: __________________________________ Date:__________________
In accordance with the Medical Staff Bylaws and Rules and Regulations, I agree to accept full legal and
ethical responsibility for the supervision of the above Physician Assistant’s performance of the duties and
acts authorized for him/her while under my supervision.
Signature of Supervising Physician (for PA’s) __________________________________Date: _______
I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and
recommend approval.
Department Chair’s Signature: ___________________________________Date: ________________
Broadway Campus