NURSING CLINICAL PRIVILEGES
Department : Ward (For New Joiners/ Speciality
Change)
Photograph
Name of the Hospital Location:
Name of the Staff:
………………………………………...………………………..…………
…………………………
EMP. ID. : Date: Date: ………… Date: …………… Date: ………
………………………………… …………
KEY ----- G – GRANTED , GWS – GRANTED WITH SUPERVISION , D - DENIED
Existing
Privileges
Previous Exp. in Ward (in as Sought 0-1 Month 1-3 Month 3-6 Month Remarks
by the
Years) : ………………
Employee
Privileges
BASIC PRIVILEGES G GWS D G GWS D G GWS D
Asked
Admission, Discharge and Transfer
Process
Patient Hygienic Care (Bed bath, Optimal
Skin Care, Back Care, Perineal Care,
Mouth care, Hair Care, Nail Care, Ear
Care, Nose Care, Eye care)
Special Care (Pressure Point care,
poisioning, Diaper care, IV site care,
Central Line care, HD cath Care, DVT
pump care, Arterial line care, Epidural
care)
Patient Assessment (Vital sign, MEWS,
Height, Weight)
Topical administration
Eye/ear/nasal drops
Steam inhalation
Nebulization
Enema/rectal suppositories
Preparation of Infusions (IV & Epidural)
Safe Infusion Management
Skin patches
Administration of drugs via Infusion
pump/ syringe pump
Administration of High Alert Medicines
(I/V, I/M, S/C) and Narcotic Drugs
Female/male Catherterization and care of
Catheter
Blood transfusion and Management of
Blood Transfusion Reaction.
I V Cannulation ,Sample collection and
Care of Peripheral lines
Carry out Hospital Infection Control
Practices & Barrier and Reverse Barrier
Nursing
Management of Hypoglycemia
Cardiopulmonary Resuscitation (BLS)
Nebulization and oxygen Administration
Assisting Ward Procedures
Managemnet of Spill and other Incident
Protocol
Management of Pain
Early Warning Signs (MEWS)
Equipment Handling (Biomedical )
Privileges
CORE PRIVILEGES G GWS D G GWS D G GWS D REMARKS
Asked
ABG Analysis
Dressing / Assist in Major Dressings
Pre & Post operative Care
Oro-Naso and Tracheostomy Suction
NG Tube Insertion, Gastric
Gavage/Lavage
Colostomy/ Ileostomy Care
PEG Feed Management
Care of Central Lines
Care of tubing / Catheter
Lumbar puncture
Thoracentesis / Paracentesis
Abdominal paracentesis
Chest tube insertion
Pleural aspiration
Removal of drains/tubes
Others (Please Specify) :
I hereby certify that I am sound by physical and mental health
Name/ Signature of Applicant Date:
Nursing Regn. Number: ………………..………………
Note : The privileges needs to be revised in case of transition in any other department ,confirmation and upgradation to the next higher designation
DO NOT WRITE BELOW THIS LINE
DNS/ANS
RECOMMENDED BY : Date:
/NO
………………..………………
Chief
APPROVED BY : Nursing
Officer Date:
………………..………………
AIMS/HR/FRM/017/VER3.2/MAY 23
