Hygienists must formally request privileges in order to provide client care in our office. This process ensures that we grant privileges based upon evidence of competency in those areas requested by the professional.
1. Privileging Form – This form indicates the types of privileges sought.
2. Support Documentation:
a. Hygiene degree
b. Continuing education
3. Review of Application for Credential/Privileges – our Govering Body includes ____________
and they are responsible for granting credential/privileges. The following mechanisms will be utilized to determine credential/privileging.
a. Professional’s documentation
c. Client Record Review
4. Decision – The privileging decision is indicated on the privileging form and the decision is communicated to the individual seeking privileges. Final approval is provided by Dr. _________. The documentation is in the professional’s file while he is kept employed here.
5. Peer Review – Credentials and Privileges are reviewed 1-2 times annually by the Peer Review Group. Their review process includes information from client records client (grievances), Professional Mentoring/Performance information, client care observation and other (references, hospital credentials, experience, continuing education, etc.). Each hygienist will be peer reviewed by the other hygienists on her team. This peer review report will be given to Dr. _________, who upon discussion with ____________, will make a final credentialing decision.
Acknowledgment of Privileging Protocol
I have read and understand the attached professional protocol. I understand that I must complete the privileging form in order to update my credentialing file. I further understand that I must complete a new privileging form in the event that I would like to expand the privileging granted to me currently.
Clinical Privileges Request Form
Check Privileges Required (Assignment of clinical privileges will be based on education, training, experience, and demonstrated current competence):
APPROVED WITHOUT LIMITATION
APPROVED- REQUIRES QUALIFIFED SUPERVISOR
APPROVED WITH MODIFICATIONS
A. ANESTHESIOLOGY & PAIN CONTROL
1) Intraoral block & conduction anesthesia with local anesthesia
2) Nitrous oxide analgesia
1) Scaling and root planing
2) Placement of chemicotherapeutics
Check Privileges Required (Assignment of clinical privileges will be based on education, training, experience, and demonstrated current competence), APPROVED WITHOUT LIMITATION APPROVED- REQUIRES QUALIFIFED SUPERVISOR APPROVED WITH MODIFICATIONS NOT APPROVED
I. RADIOGRAPHIC PROCEDURES
1) Intraoral radiographs
2) Panographic radiographs
3) Other (specify)
These privileges are requested, with the understanding that I am qualified to provide care or make appropriate referrals for this care for the full range of patients seen, taking any age- or gender-related physical, psychosocial or cultural needs into consideration, and with the understanding that I will provide the continuous care for patients assigned to me.
I understand that the completion of these forms does not preclude me from requesting additional privileges in accordance with additional experience and training.
Hygienist Signature Date
Credentialing and Re-Credentialing date___________________
Yes No N/A Follow-Up
1. Hygiene school verification
2. Valid State License
3. Continuing education current
4. State Board of Dental Examiners – No problem
5. Creditialing Committee and/or Consultation Review
6. BLS Certification
Office Manager Date