Kingdom of Saudi Arabia

‫المملكة العربية السعودية‬

MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

THE EMERGENCY DEPARTMENT
NAME: EMPLOYEE NUMBER:
ID NUMBER: YEARS OF EXPERIENCE:
SAUDI COUNCIL REGISTRATION #: DATE OF EXPIRATION:

Designation:

 RESIDENT  SPECIALIST  CONSULTANT

Certification/s:
 BCLS  ACLS  ATLS  PALS  Other/s (please specify)________________

Clinical Privilege Category:

 TEMPORARY  APPROVED  EMERGENCY
At the time of a life-threatening clinical emergency, any Practitioner may render whatever care he/she believes to be
indicated regardless of the extent of his/her granted privileges.

Instructions:
APPLICANT: In the first column below, place a check in the appropriate box whether you have requested for the privileges
listed on the second column.
GENERAL INSTRUCTION: Please tick () in the appropriate column whether the privileges that the applicant applied for
is “GRANTED”, “GRANTED WITH SUPERVISION” or “DENIED”. (If the requested privileges are either
“GRANTED WITH SUPERVISION” or “DENIED”, the “REMARKS” column may be necessary to be filled up).
Note: A copy of this privilege list will be given to the applicant. The original privilege list will be kept in the “Personnel
File”. The Clinical Privilege of Medical Staffs will be reviewed every 2 years along with their Annual Evaluation for Contract
Renewal or as necessary. (For New Medical Staffs, review of privilege will be after 90 days from the start of employment.)

REQUESTED GRANTED
CLINICAL
PROCEDURES
GRANTED WITH DENIED REMARKS
YES NO SUPERVISION
GENERAL (BASIC) PROCEDURES
  Admitting Privileges   
Conscious IV Sedation
  (May require Anesthesia   
approval)
CORE PRIVILEGES
  Treat, perform history and   
physical exam, and provide
MS-001 (2) Page 1 of 3
Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

THE EMERGENCY DEPARTMENT
care to patients presenting
in emergency department
Order diagnostic/therapeutic
  services limited to ER   
protocols
  Request consultation   
Management of problems in
    
pain relief
Suturing of uncomplicated
    
superficial wounds

REQUESTED GRANTED
CLINICAL
PROCEDURES
GRANTED
WITH DENIED REMARKS
YES NO SUPERVISION
RENDER ANY CARE IN LIFE THREATENING EMERGENCY
  Cardiopulmonary resuscitation   
Naso Gastric Tube & Urinary
    
Catheter insertion
Simple Cast Application for
  Non Fractured Cases (For   
immobilization purposes)
ORDERING BLOOD TRANSFUSION AND INFUSION
Infusion (IV Fluids, plasma,
    
etc.)
  Intravenous medicines   
Transfusion of blood and
    
blood products

If at any stage you wish to perform any surgical or therapeutic procedure that is not listed in this application, you must refer
to the Credentialing and Privileging Committee.

CLINICAL PRIVILEGES APPROVAL

STAMP &
NAME & DESIGNATION DATE
SIGNATURE
Requested by:

___________________________

MS-001 (2) Page 2 of 3

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

THE EMERGENCY DEPARTMENT

Dr. AMMAR KABBASHI

Recommended by:
Head of Emergency Department

Dr. Musaab Salih

Medical Director/
Medical Credentialing & Privileging
Approved by: Committee Chairman

Mr. Ibrahim Hamad Mana Al Amer

Hospital Director

MS-001 (2) Page 3 of 3