TRINITY MEDICAL CENTER

SEXUAL ASSAULT NURSE EXAMINER (SANE)

REQUEST FOR PRIVILEGES
NAME: ______DATE: ______

Basic Education: Registered Nurse

Minimal Formal Training: Documentation of successful completion of the approved S.A.N.E. Classroom and Clinical Training . A letter from the Program Trainer is required AND Certificate validating classroom completion.

Licensure: Current unrestricted RN Texas license, current SANE Certification (CA/CP SANE) from the Office of the Attorney General

Required Previous Experience: Minimum two (2) years of experience as a Registered Nurse preferably in an acute care setting

Required: Active member in good standing of the Denton County Sexual Assault Nurses Team

References: Three letters of reference are required to include at least one board certified physician who is familiar with your skills, AND any of the following: (1) training program director; (2) clinical preceptor or clinical faculty; or (3) chairman of clinical department from your primary practice site for the previous three years.

Licensure and Malpractice Coverage: Must have current unrestricted Texas license and malpractice coverage in the amounts of 200,000/600,000.

Advancement to non provisional status: Documentation of clinical activity within the scope of core privileges requested, without significant quality variations identified.

Reappointment requirement: Documentation of clinical activity within the scope of privileges requested, without significant quality variations identified.

Medical record responsibilities: Clearly, legibly, completely and in a timely fashion describe each service he or she provides to a patient in the hospital and relevant observations.

Name Badge – Must wear Trinity Medical Center name badge at all times

Orientation – All approved applicants will receive an orientation packet

Supervising Physician Requirement:

The Medical Director for the SANE Program shall recommend an individual applying for clinical privileges as a Sexual Assault Nurse Examiner to the Credentials Committee. The applicant shall participate in the management and care of patients only under the general supervision or direction of the Supervising Physician.

Supervising Physician means any physician currently licensed by the State of Texas who has obtained approval from the Board of Medical Examiners to supervise the specific Sexual Assault Nurse Examiner and is a current member in good standing of the medical staff of Trinity Medical Center.

*** Privileges requested must not exceed the scope of privileges beyond the sponsoring physicians***The SANE shall provide within the education, training and experience of the SANE, medical services that are within the scope of their education.

___ SANE NURSE PRIVILEGES:

All of the following privileges may be performed as part of the Adult Sexual Assault and Pediatric Sexual Assault Program.

Please draw a line through privileges not being requested.

·  A medical/forensic examination to include but not limited to the following:

·  History and Physical Exam including breast exam, detailed genital inspection, speculum exam, and use of the Colposcopy to aid in visualization

·  Venipuncture

·  Urinary Bladder Cath

·  Administration of Medications

·  Collection of Laboratory Specimens

·  Skin Tests: Performance and Reading

·  Injections

·  Superficial Wounds: Care and Debridement

·  Recognition, collection and preservation of forensic specimens

Acknowledgement of Practitioner:

I have requested only those services for which by education, training, current experience, and demonstrated performance, I am qualified to perform and which I wish to exercise at Trinity Medical Center. I possess the ability and necessary health status to fulfill the responsibilities of an Allied Health Professional.

I understand that in exercising any specific services granted and in carrying out the responsibilities assigned to me, I am constrained by any hospital and medical staff policies and rules applicable generally and any applicable to the particular situation. Any restrictions on the specified services granted to me is waived in an emergency situation, and in such situation, my actions are governing by the applicable section of the policies governing allied health professionals.

SANE Date:

______

Supervising Physician’s Signature: Date:

______

Department Chairman Date

Chief Nursing Officer Date:

Approvals: Department of Emergency Medicine 5/19/05 Credentials Committee: 6/2/05 Medical Executive Committee: 6/8/05 Governing Board: 6/15/05

Annual Review: Department: 5/18/06; Credentials: 6/1/06 MEC: 6/14/06 Governing Board: 6/21/06