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

ENT (EARS, NOSE, THROAT)

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”. This list of clinical privilege will be reviewed every 2 years along with the Medical Staff
Contract Renewal or as necessary.

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION
GENERAL (BASIC) PROCEDURES
  Admitting Privileges   

MS-001 (2) Page 1 of 5

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

ENT (EARS, NOSE, THROAT)
Conscious IV
Sedation
    
(May require
Anesthesia approval)
CORE PRIVILEGES
  Adenoidectomy   
  Tonsillectomy   
Excision of lesions, local
  (brachial, thyroglossal cyst,   
polyps, etc.)
  Major lesions   
  Laryngotomy   
  Myringotomy   
  Tracheotomy   

REQUESTED Granted
Clinical Procedures Granted With Denied REMARKS
YES NO Supervision
CORE PRIVILEGES-CONTINUATION
  Mastoidectomy simple   
  Radical   
Sinus-insicion and
    
drainage
  Submucous resection   
  Ear surgery – minor   
  Ear surgery – major   
  Radical neck dissections   
  Meatoplasty   
  Tympanoplasty   
  Cortical mastiodectomy   
  Excision of concha bullosa   
Management of
    
uncontrolled epistaxis

MS-001 (2) Page 2 of 5

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

ENT (EARS, NOSE, THROAT)
Uvelo-palato-pharyngo-
    
plasty UPPP
Repair of pharyngeal
    
trauma
  Major laryngeal surgery   
  Excision of laryngeal polyp   
  Excision of laryngeal web   
Foreign body removal
    
(throat)
Removal of foreign body in
    
nasal cavity
Removal of foreign body in
    
ear canal
Removal of foreign body in
    
upper esophagus
Removal of foreign body in
    
bronchus
  Incision of nasal furuncle   
  Incision of ear furuncle   
Incision of peritonsillar
    
abscess
  Replace of ruptured drum   
  Partial excision of uvula   
  Excision of aural polyp   
  Excision of nasal polyp   
  Excision of throat polyp   
Evacuation of septal
    
hematoma
Evacuation of auricular
    
hematoma
Reduction of fracture nasal
    
septum

MS-001 (2) Page 3 of 5

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

ENT (EARS, NOSE, THROAT)

REQUESTED Granted
Clinical Procedures Granted With Denied REMARKS
YES NO Supervision
CORE PRIVILEGES-CONTINUATION
Reduction of fracture nasal
    
bone
  Septoplasty   
  Otoplasty   
Partial inferior
    
turbinectomy
  Partial middle turbinectomy   
  Opening choanal atresia   
BLOOD TRANSFUSION AND INFUSION
Infusion ( IV Fluids,
    
plasma, etc.)
  Intravenous medicines   
Blood transfusion- whole,
    
packed cells
  Tenorrhapy   
  Excision of ganglion cysts   

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:
___________________________

Recommended by:

MS-001 (2) Page 4 of 5

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

ENT (EARS, NOSE, THROAT)
Head of ENT Department

Dr. Anwer Nehal Ghouri

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

Mr. Ibrahim Hamad Mana Al Amer

Hospital Director

MS-001 (2) Page 5 of 5