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PAGE 1 OF 12Fairview Health ServicesNURSE PRACTITIONERDelineation of PrivilegesApplicant’s Name (please print):CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGESI Want to Work at the Following Fairview EntityInpatient/hospital(s)Fairview Maple Grove Medical Center(Ambulatory Care Center) 1, 2Fairview Maple Grove Ambulatory Surgery CenterFairview Hospital-Based Clinic1I need to the following Fairview Entity Box on Privilege FormIndividual Fairview hospital(s)University of Minnesota Medical Center, Fairview (UMMC)Fairview Maple Grove Ambulatory Surgery Center (MGASC)(such as UMMC Clinics, Fairview Ridges Specialty Clinic forChildren, Fairview Southdale Oncology Clinic, FairviewSouthdale Hospital Breast Center)1, 3Individual Fairview hospital where clinic is affiliatedFairview Free-Standing Ambulatory Clinics1Fairview Group Practice Ambulatory Clinics (FV Clinics)1Ambulatory privileges to practice at Fairview hospital-based clinics and other non-hospital-based Fairview owned entities are only available tothose practitioners authorized by Fairview to practice at those sites. Ambulatory privileges do not include performance of procedures which are nototherwise available or performed at the individual ambulatory sites as determined by the operational manager or other appropriate personnel.2Privileges granted by UMMC can also be exercised at the Maple Grove Ambulatory Care Center in accordance with procedures available at this site.3Privileges granted by the specific hospital entity can also be exercised at hospital-based clinics affiliated with that entity in accordance withprocedures available at the clinic.THRESHOLD CRITERIADegreeRNEducationCompleted a masters degree in nursing or post graduate program in nursing specific to the area of advanced practice nursingORMeet the education requirements for certification by a national nurse certification organization acceptable to the MinnesotaBoard of Nursing for advanced practice nursingLicensureMust hold current Minnesota RN licenseBoardCertificationMust be Board Certified by a national nurse certification organization acceptable to the Minnesota Board of Nursing and specificto the area in which you wish to practice (see Threshold Criteria listed in individual privilege sections)ORMust be within 6 months after completion of an advanced practice nursing course of study and in the process of meeting therequirements for certification. If you fail the certification examination, you must stop practicing as an advanced practiceregistered nurse (per MN Board of Nursing).SponsorshipNurse practitioners practicing in a Fairview entity are sponsored staff and required to have a physician sponsor who is in goodstanding on staff at the Fairview entity to which the applicant is Sponsoring/supervising physician must hold privileges for the procedures you are requesting at the hospital to which you areapplying.The applicant must have a signed Fairview Nurse Practitioner/Physician Collaborative Practice Agreement with a physician ingood standing on the staff at the Fairview entity to which the applicant is applying and have prescriptive authority through theMinnesota Board of Nursing. The Collaborative Agreement is attached.SUPERVISION LEVELSGeneralSupervisionThe care, activity or procedure is provided or performed under the physician’s oversight and overall direction and control, but thephysician’s presence is not required while it is being provided or performed. The physician accepts responsibility and liability forthe quality of care provided by the person being supervised. Core privileges are performed under General Supervision unlessotherwise stated.DirectSupervisionThe physician is present in the area and immediately available to furnish assistance and direction throughout the time the care,activity or procedure is provided or performed. It does not mean the physician must be present in the room while the procedure isperformed. The physician accepts responsibility and liability for the quality of care provided by the person being supervised.PersonalSupervisionThe physician must be in attendance in the room while the care, activity or procedure is provided or performed. The physicianaccepts responsibility and liability for the quality of care provided by the person being supervised.Q:\Central Metro-Shares\UMMC Business\Share Dir\Credentialing Dept\Privilege Forms\Nurse Practitioner.docRevised: 10/01; 6/02; 12/02; 1/04; 1/05 (subcomm); 3/06; 8/06 (subcomm); 1/07 (subcomm); 6/07 (subcomm); 9/07; 3/08; 5/08; 7/8/08 (subcomm); 9/08; 6/09 (new format); 9/14/09; 12/09; 2/10; 6/11; 7/11; ;6/14
PAGE 2 OF 12Fairview Hospital Entity CodesUMMC - University of Minnesota Medical Center, FairviewFSH - Fairview Southdale HospitalFRH - Fairview Ridges HospitalFNH - Fairview Northland Medical CenterFLH - Fairview Lakes Medical CenterFairview Ambulatory Entity CodeFV Clinics Fairview Free-standing Ambulatory ClinicsMGASC Fairview Maple Grove Surgery CenterDefinitions/AbbreviationsCore Privileges - Privileges routinely taught in training programsSpecial Request Privileges - Privileges not routinely taught in training programs; new technology or procedure; high risk; or requiresongoing practice to maintain competencyN/A - Indicates privilege not available at the specific Fairview entityAF - Indicates an additional form is required to request the privilegeADULT/GERONTOLOGY NURSE PRACTITIONERThresholdCriteria Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification in the area of Acute, Adult, Family Medicine, Women’s Health or GerontologyCross out privileges you do not performCorePrivilegesCheck Entity(ies) Where Privileges RequestedPrivileges include providing general health care andHospital EntitiesAmbulatorytreatment of adult patients including examination ofpatients, performance of health histories and physicalUMMCFSHFRHFNHFLHFV Clinicsexams, ordering, interpreting and evaluating diagnostictests and recording findings. Privileges also include: Performing minor surgical procedures such as punchbiopsy, sebaceous cyst and ingrown toenail removaland repair of minor lacerations with no nerve, tendon or major vessel involvement Management of non-displaced fractures and sprains including casting, insertion and removal of drains May assist sponsoring physician in surgery or with other treatment procedures Care of indwelling vascular catheters, chest tubes, gastrostomy tubes, gastrojejunostomy tubes, cecostomy tubessclerotherapy tubes, and abscess drainage tubes Order restraints per Fairview policyCore privileges do not include prescribing privileges (see Prescriptive Core)MAPLE GROVE AMBULATORY SURGERY CENTERThresholdCriteriaCorePrivileges Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification in the area of Acute, Adult, Family Medicine, Women’s Health or GerontologyCross out privileges you do not performCheck Entity(ies) Where Privileges RequestedPrivileges include ability to evaluate, diagnose, andprovide pre-, intra- and postoperative care, treatment,and services consistent with surgical practice, includingthe performance of physical exams, diagnosingconditions, the development of treatment plans, healthcounseling, prescribing medications, and assisting insurgery for patients within the age group of patientsseen by the collaborating/supervising physician. Writingappropriate pre and post operative orders. See SpecialRequests (page 9). Collaborative Agreement (attached).Maple Grove Ambulatory Surgery Center box for MGASC
PAGE 3 OF 12PEDIATRIC NURSE PRACTITIONERThresholdCriteria Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification in the area of Pediatrics or Family MedicineCross out privileges you do not performCorePrivilegesCheck Entity(ies) Where Privileges RequestedPrivileges include providing general health care,Hospital EntitiesAmbulatorytreatment and management of common pediatricillnesses of patients from infancy through young adult.UMMCFSHFRHFNHFLHFV ClinicsPrivileges include Examination of patients, performanceof health histories and physicals based on age andhistory, ordering, interpreting and evaluating diagnostictests and recording findings, developmentalassessments. Privileges also include: Performing minor surgical procedures such as punch biopsy, sebaceous cyst removal and repair of minor lacerationswith no nerve, tendon, or major vessel involvement Management of non-displaced fractures and sprains including casting, insertion and removal of drains May assist sponsoring physician in surgery or with other treatment procedures Care of indwelling vascular catheters, chest tubes, gastrostomy tubes, gastrojejunostomy tubes, cecostomy tubessclerotherapy tubes, and abscess drainage tubes Order restraints per Fairview policyCore privileges do not include prescribing privileges (see Prescriptive Core)NEONATAL NURSE PRACTITIONERThresholdCriteriaCorePrivileges Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification in the area of Neonatal Must be an employee of or hold a contract with Fairview Health SystemCross out privileges you do not performCheck Entity(ies) Where Privileges RequestedPrivileges include provision of general health care andHospital EntitiesAmbulatorytreatment of neonatal patients in the NICU or Level IINursery. Privileges include:UMMCFSHFRHFNHFLHFV Clinics PIV Venipuncture PICC insertion and removalN/A N/AN/A Radial, brachial arterial stick UAC and UVC insertion/removal Pericardiocentesis Endotrachial intubation Management of mechanically ventilated patients Chest tube insertion/removal Percutaneous arterial line placement/removal Needle aspiration May also attend high risk deliveries and transport critically ill neonates Suprapubic bladder tap Care of indwelling vascular catheters, chest tubes, gastrostomy tubes, Lumbar puncturegastrojejunostomy tubes, cecostomy tubes sclerotherapy tubes, and abscess Thoracentesisdrainage tubes ParacentesisCore privileges do not include prescribing privileges (see Prescriptive Core)
PAGE 4 OF 12PSYCHIATRY NURSE PRACTITIONERThresholdCriteria Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification in the area of Mental HealthCross out privileges you do not performCorePrivilegesCheck Entity(ies) Where Privileges RequestedPrivileges include:Hospital EntitiesAmbulatory Conducts comprehensive psychiatric assessmentsincluding but not limited to psychosocial history,UMMCFSHFRHFNHFLHFV Clinicsmental status examination, medical/neurologicalhistory, physical findings and laboratory tests withinprotocol guidelines and within context ofN/AN/AN/A N/AN/Acollaborative management Perform individual, couple, group and family psychotherapy and/or education Initiate admitting starting orders within context of collaborative management Participate in the administration of psychometric testing and other investigatory tests as is appropriate Perform face to face assessments for restraint and seclusion Initiate and discontinue 72 hour holds Discharge patients Order restraints per Fairview policyCore privileges do not include prescribing privileges (see Prescriptive Core)EMERGENCY SERVICES NURSE PRACTITIONERThresholdCriteria Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification Must be employed by or under contract with an entity whose employees or agents are otherwise able to provideprofessional emergency services within the applicable Fairview hospital’s Emergency Department Sponsoring/supervising physician must be an emergency medicine physician who is employed by or under contractwith the applicable Fairview hospital’s Emergency DepartmentCross out privileges you do not performCorePrivilegesCheck Entity(ies) Where Privileges RequestedPrivileges include, but are not limited to, assessment ofHospital EntitiesAmbulatorythe *patient’s medical, physical and psychiatric status,including patient histories, physical exams. PrivilegesUMMCFSHFRHFNHFLHFV Clinicsalso include: Assisting with and/or practicinginterventions/procedures as delegated by theN/AN/Acollaborating physician or designated alternate Ordering diagnostic tests, activities, therapies, diet and vital signs, IV fluids, blood and blood products, oxygen Recording diagnostic impressions, interpreting and evaluating patient data Instruct, educate, and counsel patients on health status, test results, disease process, and planning, creating andmaintaining appropriate patient records Consultation with medical staff members Assess all patients in order to determine if more definitive services are necessary Procedures such as suture removal, wound checks, needlesticks, Rabies shots Treatment of minor lacerations, simple puncture wounds (no neck or abdominal), rashes (not petechial), abrasions,contusions, tooth and/or earache, sunburn, conjunctivitis, cough, foreign bodies to ear/nose/extremities, neck pain,back pain, URI, UTI Treatment of sprains, strains, simple fractures (suspected at triage, no deformity noted) of digits, hand, wrist, toe,foot, ankle, and knee Order restraints per Fairview policyCore privileges do not include prescribing privileges (see Prescriptive Core)Within the scope of these privileges, it is intended that the nurse practitioner be a qualified medical person forpurposes of performing medical screening examinations under the Emergency Medical Treatment and Active Labor Act.42 USC 1395dd.
PAGE 5 OF 12CARDIAC CATH LAB NURSE s forCardiacCath LabPrivileges Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification Must meet Additional Requirements for Cardiac Cath Lab listed belowInitial Appointment:1) Must document training completed within past 24 months specific to all procedures within the core OR documentassistance with a minimum of 100 cardiac cath lab cases within the past 24 monthsAND2) Must document completion of Radiation Safety Training within past 24 monthsAND3) Must document current Basic and Pediatric Advanced Life SupportAND4) Must be employed by or under contract with the University of Minnesota Physicians or Fairview Health Services toprovide services in the Cardiac Cath Lab at the University of Minnesota Medical Center, FairviewReappointment:1) Must document assistance with a minimum of 100 cardiac cath lab cases within the past 24 monthsAND2) Must document current Basic and Pediatric Advanced Life SupportAND3) Must be employed by or under contract with the University of Minnesota Physicians or Fairview Health Services toprovide services in the Cardiac Cath Lab at the University of Minnesota Medical Center, FairviewCross out privileges you do not performCorePrivilegesCheck Entity(ies) Where Privileges RequestedPrivileges include participating in an ASSISTANT ROLEHospital EntitiesAmbulatorywith patients of any age under the identified supervisionlevel of a cardiologist with appropriate privileges andUMMCFSHFRHFNHFLHFV Clinicsincludes (supervision levels are defined on page 1):General Supervision Performs health history, physical examination, andN/AN/AN/A N/AN/Aongoing assessment of patients with congenital oracquired heart disease or dysrhythmia Perform patient/family teaching for CHD lesions, cardiac catheterization, and all planned interventional therapy Differentiates between normal findings and those that require treatment, consultation, and/or referral Obtain informed consent for cardiac catheterization, administration of blood products and transcatheterinterventions Provides interpretation of laboratory studies, ECG, and echocardiographic interpretation Discharges patientDirect Supervision Obtain central venous and arterial access with sheath placement Operate fluoroscopy equipment Camera angulation appropriate for planned angiograms Right and left heart catheterization with hemodynamic monitoring Insert, manipulate and maneuver catheters and guidewires Diagnose and treat patients with congenital or acquired heart disease, abnormal heart rhythms in conjunction withthe Interventional Cardiologist. Maintains appropriate anticoagulation Removes pericardial drainsPersonal Supervision Assist with Diagnostic Angiography First Assist in Interventional Therapeutics Insert, manipulate and maneuver catheters and guidewires Deliver injectable coils Inflate/deflate angioplasty balloons Deliver, deploy, release of devicesCore privileges do not include prescribing privileges (see Prescriptive Core)
PAGE 6 OF 12ADVANCED FIRST ASSIST NURSE s forAdvancedFirstAssistPrivileges Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification Must meet Additional Requirements for Advanced First Assist listed belowInitial Appointment:1) Must document successful completion of an accredited RN First Assist training program completed within the past 24months OR document working as a First Assist with a minimum of 80 cases within the past 24 months OR providedocumentation from sponsoring physician detailing First Assist trainingAND2) Must document training specific to all the procedures listed under the coreAND3) Must be employed by or under contract with the University of Minnesota Physicians or Fairview Health Services toprovide services in the Operating Room at the University of Minnesota Medical Center, FairviewReappointment:1) Must document working as a First Assist with a minimum of 80 cases within the past 24 monthsAND2) Must be employed by or under contract with the University of Minnesota Physicians or Fairview Health Services toprovide services in the Operating Room at the University of Minnesota Medical Center, FairviewCross out privileges you do not performCorePrivilegesPrivileges include participating in an ASSISTANT ROLEwith patients of any age under the identified supervisionlevel of a surgeon with appropriate privileges andUMMCincludes (supervision levels are defined on page 1):General Supervision Remove chest tubes Insert chest tubes Remove temporary epicardial pacing wires Removal of transthoracic intercardiac cathetersDirect Supervision Make incision Superficial dissection Placement of epicardial pacemaker wires Providing hemostasis with topical preparations Insert central venous and arterial lines Place pericardial membranePersonal Supervision Assist with deep dissection Assist with thoracotomy Placement of direct RA/PA lines Obtaining direct blood samples from PA Adjusting bands and snares Cannulating and decannulating Tying down cannulation suture Saphenous vein harvestingMay perform emergent re-entry for tamponade/clotted shuntCheck Entity(ies) Where Privileges RequestedHospital EntitiesFSHCore privileges do not include prescribing privileges (see Prescriptive Core)AmbulatoryFRHFNHFLHFV ClinicsN/AN/AN/AN/A
PAGE 7 OF 12INTERVENTIONAL RADIOLOGY NURSE PRACTITIONERThresholdCriteria Must meet all Threshold Criteria listed on page 1AND Current Nurse Practitioner certification Must be employed by or under contract with a physician group that is able to practice interventional radiology at theUniversity of Minnesota Medical Center, FairviewCross out privileges you do not performCorePrivilegesCheck Entity(ies) Where Privileges RequestedPrivileges include assisting supervising/collaboratingHospital EntitiesAmbulatoryphysician with procedures. Privileges also include: Performance of health histories and physical examsUMMCFSHFRHFNHFLHFV Clinics Consultation and treatment of patients admitted forinterventional radiology proceduresN/A N/AN/A Initiating requests for commonly performedlaboratory studies Performance of venipunctures, intubation of gastrointestinal tract and blad
Meet the education requirements for certification by a national nurse certification organization acceptable to the Minnesota Board of Nursing for advanced practice nursing . Care of indwelling vascular catheters, chest tubes, ga
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