Banner Baywood Medical Center
Scope of Practice/Delineation of Privileges
Allied Health Professional
FAMILY NURSE PRACTITIONER
Practitioner Name: ______________________________________________________
Definition/Scope of Practice
Only Nurse Practitioners with the corresponding specialty certification may be privileged for the
corresponding essential functions, core privileges and population. Family NP (FNP) assesses health status,
diagnoses health status, and plans care to address healthcare needs of individuals and families across the
lifespan. Population focus for the FNP is individuals and families across the lifespan and communities
whose healthcare needs include disease prevention, health promotion, management of acute self-limited
and chronic stable single or multi-system health problems and end of life care.
FNP’s shall be under the supervision of their supervising physician who shall review all data, summaries,
progress notes, directions, or other information entered into the medical record or chart of a patient by a
Nurse Practitioner within 24 hours. Nurse Practitioners must identify self and supervising physician on
all documents, i.e. (Jane Doe, FNP/Dr. Smith).
Qualifications:
a) Current sponsorship by physician member in good standing of the Medical Staff of
Banner Baywood.
b) Completion of an approved, accredited nurse practitioner program that teaches the
expanded nursing skills and knowledge relative to persons in the area of primary
practice.
c) Provide proof of malpractice coverage in the amount acceptable to the hospital
(currently $1M and 3M). This coverage may be independent coverage or as an
endorsement on the supervising physician’s malpractice declaration.
Required Certification and Licensure:
a)
b)
c)
d)
Current License granted by the Arizona State Board of Nursing
Current Nurse Practitioner (NP) certificate from Arizona State Board of Nursing
Current CPR certification.
Current DEA registration certificate for prescribing authority.
Essential Functions and Core Privileges:
Requested Approved
________ ________ Core privileges include: conducts health interviews and physical exams;
assigns a diagnosis; plans and implements treatment; orders and interprets diagnostic tests; performs
noninvasive therapeutic interventions and tests; monitors invasive diagnostic, therapeutic and
interventional measures and tests; prescribes medications; consults with and to other healthcare
professionals; provides counseling and teaching for patients, families, communities, and other
healthcare professionals; initiates referrals to other members of the healthcare team for concurrent
and/or continuing care; performs suturing, splinting, removal of minor foreign bodies from skin excluding
ophthalmic area.
Family Nurse Practitioner
Allied Health Professional
Page 2
Special Procedure Privileges: The applicant must demonstrate successful completion of an approved
and recognized course; and provide documentation of competence in performing that procedure
consistent with the criteria set forth below.
Requested Approved
________ ________ Moderate Sedation: Requires ACLS and/or PALS certification and
evidence of successful completion of Banner Learning Center sedation module.
________ ________ Reduction of fractures/dislocations
________ ________ First Assist at Surgery: Requires RN degree, Completion of CCI
(Certification and Credentialing, Inc.) approved RNFA program and Certified Nurse Operating
Room (CNOR) certification. CRNFA preferred, but not required.
Assist with positioning and patient preparation, assist with or drape surgical field. Under the
direct supervision of the sponsoring physician/surgeon, the RNFA may assist in the performance
of the following functions: tissue handling; provide surgical field exposure; provide hemostasis;
and utilize surgical instrumentation properly and assist with power equipment, orthopedic
hardware or other devices as deemed necessary through the critical portion of the procedure.
Once the critical portion of the procedure is complete, under the proximal supervision of the
surgeon, the RNFA may assist with or perform wound care closures, skin sutures, and skin
dressings.
________ ________ Robotics Assisting: Requires evidence of completion of on line
training and/or service/training with Intuit representative or if prior experience with robotics, case
log, and competency assessment must be submitted; proficiency in laparoscopic surgery
assisting required (minimum five cases); applicants without prior robotic assisting experience
must observe two cases performed by experienced assist at surgery; first two cases must be
observed by experienced assist at surgery with unobserved robotic assisting privileges. The
observer must be there for the majority of the case during docking of robot, placing ports, etc.
________ ________ Interpret EKG’s and cardiac rhythm strips: (Requires education and
training specified by Department and 25 directly-supervised cases)
________ ________ Other: _________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Family Nurse Practitioner
Allied Health Professional
Page 3
Acknowledgement of Applicant
I have requested only those procedures for which by education, training, current experience, and
demonstrated performance I am qualified to perform, and that I wish to exercise at Banner Baywood
Medical Center.
Signed: __________________________________________ Date: _______________________
(Applicant’s Signature)
Department Chair’s Recommendations:
I have reviewed the requested privileges and supportive documentation for the above named applicant
and recommend action on the request as noted above.
________ Approved
________ Approved with Modifications
________ Not Approved
Comments: ______________________________________________________________________
Signed: __________________________________________ Date: _______________________
(Department Chair)
Approved by Governing Board: June 20, 2014