Attachments - PHC - Family Medicine Privileging Form - May 2023 (Consultant and Senior ...

‫المملكة العربية السعودية‬
‫وزارة الصحة‬
Kingdom of Saudi Arabia
Ministry of Health
‫تجمع الرياض الصحي الثاني‬
Riyadh Second Health Cluster ‫ادارة شؤون الممارسين الصحيين‬
Healthcare Professionals Affairs
Administration
Medical Credentialing, Privileging & Promotion Committee

Patient Care Privileges Form
INSTRUCTIONS:
 Please complete the section (s) in which you are requesting
privileges and for which you have the requisite
qualifications and experience.
Section A: Specialty
Illness or problem requiring training and skills usually
obtained during specialty board training and
certification.
Section B: Sub- Specialty

Illness or problem requiring special training and skills
usually obtained during sub-specialty training and
certification.
Section C: Additional Clinical Privileges: (if

applicable)
Special procedure(s) requiring additional training and
experience, which needs to be supported by
documentation giving evidence of training and level of
expertise attained.
Section D: Privileges Not Granted: (if applicable)

Special procedure(s) not granted by the MCPPC.
NOTE:
 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.
Patient Care Privileging Form-Primary Health (Family Medicine)- Consultant & Senior Registrar Page 1 of 10 May 24, 2023
Ministry of Health
Administration
PHYSICIAN'S NAME
PHYSICIAN'S RANK CONSULTANT/ SENIOR REGISTRAR

PRIMARY CARE
CENTER

SECTOR (‫)القطاع‬
DATE
Ministry of Health
Administration
Patient Care Privileges Form Section

A
NAME
SPECIALTY:
:
 PLEASE MARK “X” BY CLICKING THE BOX IN THE APPROPRIATE COLUMN.
 DO NOT MARK “X” MORE THAN ONE COLUMN FOR EACH PROCEDURE REQUESTED.
PRIVILEGES REQUESTED
COMMITT
SOLE MD
UNDER ASSIST E
No. FAMILY HEALTH MANAGE APPROVAL
SUPERVISION ONLY APPROVA
MENT
YES NO YES NO
1. Perform histories and physical examinations   

2. Order diagnostic and therapeutic services   
Make referrals and request consultations and render
3. care within their scope of training in a medical   
emergency
4. I and D abscess, superficial location   
5. Remove foreign body (superficial)   
6. Obstetrical: NSVD, episiotomy and repair   
Advise and provide suitable methods of family
7. planning   
Provide routine antenatal care to low risk
8. pregnancy   
Provide postnatal care, both physical and
9. psychological   
Perform routine examination of child in new born
10. period   
11. Fit IUCD   
Provide routine prevention gynecological care, e.g.
12. pelvic exams, PAP smears, high vaginal swab, etc.   
13. Gynecology (Pre-eclampsia, mild to moderate. OB)   
14. Gynecology (Prostaglandin administration OB)   
15. Pediatrics, 2 years to 13 years (Venipuncture)   
Ministry of Health
Administration

A
NAME
SPECIALTY:
:
COMMITT
SOLE MD
UNDER ASSIST E
MENT
YES NO YES NO
16. Pediatrics, 2 years to 13 years (Gynecologic exam)   

17. General Surgery (Skin/cutaneous tissue biopsy)   
18. General Surgery (I & D abscess)   
19. General Surgery (Suture lacerations, any area)   
20. General Surgery (Debridement)   
General Surgery (Excise nail. Ingrown toe nail
21. removal)   
22. ENT (Nasal cautery)   
23. ENT (Anterior and posterior nasal pack)   
24. Ear wax removal   
25. Orthopedics (Cast application and removal)   
26. Orthopedics (Arthrocentesis, large joints)   
Orthopedics (Shoulder dislocation, anterior,
27. uncomplicated)   
28. Proctoscopy   
29. Initial plain X-ray interpretation   
30. Initial management of coma   
31. Initial management of respiratory distress   
Ministry of Health
Administration

A
NAME
SPECIALTY:
:
COMMITT
SOLE MD
UNDER ASSIST E
MENT
YES NO YES NO
Initial interpretation of pulmonary function
32. spirometer   
33. Initiation and management of nebulization   
34. Treatment of minor burns   
Emergency Endotracheal intubation. (requires
35. ACLS)   
36. ECG interpretation   
Pediatrics, 3 months to 2 years (Emergency
37. Tracheal intubation) (requires PALS)   
38. Cardio-Pulmonary Resuscitation CPR   
39. Acute and Chronic Medical Management   
Consultation and render care Within scope of
40. training   
41. Acute and Chronic disease management   
Acute and Chronic medication use manage &
42. controlled substance management   
43. Lifestyle Counsiling   
44. Well baby clinic   
45. Smoking Cessations Counseling   
46. Pre-Employment Screening   
47. Antenatal Care   
Ministry of Health
Administration

A
NAME
SPECIALTY:
:
COMMITT
SOLE MD
UNDER ASSIST E
MENT
YES NO YES NO
48. Pre-natal Counseling & Screening   

49. Travelx Advice Clinic   
50. Immunization   
51. Periodic health maintenance   
Ministry of Health
Administration

B
SPECIALTY:
NAME: SUB-

SPECIALTY:
COMMITT
CHAIRMAN
SOLE UNDER ASSIST E
No. FAMILY MEDICINE APPROVAL
MANAGEMENT SUPERVISION ONLY APPROVA
YES NO YES NO
1.   
2.   
3.   
4.   
5.   
6.   
7.   
8.   
9.   
10.   
Ministry of Health
Administration
Section C
SPECIALTY:
NAME: SUB-

SPECIALTY:
ADDITIONAL CLINICAL PRIVILEGES

No. (Special Procedures)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
 ANY SURGICAL OR THERAPEUTIC PROCEDURE NOT

LISTED IN THIS APPLICATION, MUST BE REFERED TO THE
MEDICAL CREDENTIALING, PRIVILIGING & PROMOTION
COMMITTEE.

Approved by: Primary Department Chairman Approved by: 2nd Department Chairman
Ministry of Health
Administration
Section D
SPECIALTY:
NAME:
SUB-SPECIALTY:
PRVILEGES NOT GRANTED BY THE MCPPC

Category
No. Justification (Remarks)
Section A Section B Section C
Specialty Subspecialty Additional Clinical Privileges
I have requested only those privileges that by education, current experience, current ability and
demonstrated performance I am qualified to perform and that I wish to exercise at this Hospital. By
my signature below, I certify that my malpractice insurance will cover my exercise of the above
requested procedures; and I understand that:
1. In exercising any clinical privileges granted in carrying out the responsibilities assigned to
me, I am constrained by Hospital and Medical Staff policies and rules applicable generally or to a
particular situation.
2. Any restriction on the clinical privileges granted to me is waived in an emergency and in such
situation; my actions are governed by the applicable section of the Medical Staff Bylaws and
related documents.
Applicant’s Signature: Date:
Ministry of Health
Administration
Signatures
Requesting Physician: Date:

Recommended By: Date:

PHC Medical Director
Recommended By: Date:

Primary Health Sector Director
Approved By: Date:

Chairman of Primary Health Care
Privileging Committee
Cc:
 R2 Medical Credentialing, Privileging, and Promotion Committee

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‫المملكة العربية السعودية‬

Medical Credentialing, Privileging & Promotion Committee

Section B: Sub- Specialty

Section C: Additional Clinical Privileges: (if

Section D: Privileges Not Granted: (if applicable)

PHYSICIAN'S NAME

PHYSICIAN'S RANK CONSULTANT/ SENIOR REGISTRAR

SECTOR (‫)القطاع‬

Patient Care Privileges Form Section

1. Perform histories and physical examinations   

Patient Care Privileges Form Section

16. Pediatrics, 2 years to 13 years (Gynecologic exam)   

Patient Care Privileges Form Section

Patient Care Privileges Form Section

48. Pre-natal Counseling & Screening   

Patient Care Privileges Form Section

ADDITIONAL CLINICAL PRIVILEGES

 ANY SURGICAL OR THERAPEUTIC PROCEDURE NOT

PRVILEGES NOT GRANTED BY THE MCPPC

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Specialty Subspecialty Additional Clinical Privileges

Applicant’s Signature: Date:

Requesting Physician: Date:

Recommended By: Date:

Recommended By: Date:

Approved By: Date:

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