Surgical Privileges Form: ORL - HNS - QCHP | Home Privileges - Otolaryngology.pdf · Name of...

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Surgical Privileges Form: Clinical Privileges Request

ORL - HNS

Applicant’s Name: …………………………….…………… Scope of Practice: ………………………….

License No. (If Any): …………………………….…………….. Facility: ……………………………………..

Date: …………………………….……………………………………….. Place of Work: …………………………….……

CATEGORY I: GENERAL PRIVILEGES

1. Admitting privileges

2. Admission history & physical examination

3. Interpretation of laboratory tests

4. Insertion of urinary catheter 5. Peripheral intravenous catheter

insertion

6. Nasogastric tube insertion 7. Oropharyngeal airway insertion 8. Prescribing oxygen therapy

CATEGORY II: OTOLOGY PROCEDURES

1. Examination of the Ear

a. LA

b. GA 2. Myringotomy with or without

tubes

3. Removal of foreign body (aural) 4. Aural packing 5. Ear syringing

Privileges

Requested (To be

completed by the

applicant)

Recommended (For committee use)

Not Recommended (For committee

use) Under

Supervision Independent

Name of Applicant: -----------------------

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Privileges

Requested (To be

completed by the

applicant)



use) Under


6. Pinna-plasty

7. Myringo/Tympanoplasty

8. Ossiculoplasty

9. Stapedectomy

10. Mastoidectomy

a. Canal wall up

b. Sim ple

c. Modified radical

d. Radical

11. Mastoid reconstruction

12. Tympanic neurectomy

13. Cochlear implantation

14. Facial nerve exploration

15. Labyrinthectomies

16. Surgery for hydrops lymphaticus

17. Excision of glomus tumor

a. Glomus tympanicum

b. All other types

18. Petrosectomy

a. Partial

b. Total


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Privileges

Requested (To be

completed by the

applicant)



use) Under


19. Middle fossa approach

20. Posterior fossa approach

21. Ear canal osteoma excision

22. Use of laser

a. CO2 (to assist in otological surgery)

b. KTP (to assist in otological surgery)

23. Use of navigation (to assist in ontological surgery)

24. Radiofrequency assisted operation

25. Coblation assisted operation

CATORGY III: RHINOLOGY PROCEDURES

1. Examination of the nose

a. LA

b. GA 2. Nasal cautery 3. Submucus diathermy (SM D) of

turbinate

4. Nasal endoscopy 5. Antrostomy inferior (non-

endoscopic)

6. Turbinectomy 7. Antral wash 8. Nasal fracture reduction

(anterior and posterior)

9. Removal of foreign body 10. Nasal packing 11. Septoplasty 12. Septal reconstruction


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Privileges

Requested (To be

completed by the

applicant)



use) Under


13. Reconstruction of septal perforation

14. Evacuation of septal hematoma

15. Caldwel-luc operation

16. Maxillary artery ligation

17. Sinus endoscopy

18. Nasal polypectomy

19. Rhinoplasty

a. External approach

b. Internal approach

20. Lateral rhinotomy

21. Ligation of sphenpalatine artery

22. FESS

23. Classical sinus surgical operations

a. Intranasal:

i. maxillary antrectomy & antrostomy

ii. anterior ethmoidectomy

iii. posterior ethmoidectomy

iv. sphenoidectomy

b. External:

i. Ethmoidectomy external

ii. Frontal trephination


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Privileges

Requested (To be

completed by the

applicant)



use) Under


iii. Frontal ethmoidectomy

iv. Frontal sinus obliteration

v. Ligation of anterior ethmoidal cavity

24. Transposition of the nose

25. Maxillectomies

a. Medial

b. Total

26. Osteoplastic flap operations

27. Rhinoseptoplasty

28. Use of laser

c. CO2 (to assist in nasal surgery)

d. KTP (to assist in nasal surgery)

29. Use of navigation (to assist in nasal surgery)

CATEGORY IV: LARYNX, HEAD AND NECK SURGERIES

1. Examination of the larynx

a. LA

b. GA 2. I&D Quinsy 3. Tonsillectomy 4. Adenoidectomy 5. Tongue tie release 6. PNS Examination/Biopsy 7. Oropharynx

examination/biopsy

8. Fiberoptic endoscopy


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Privileges

Requested (To be

completed by the

applicant)



use) Under


9. Uvulopalatopharyngoplasty

10. Partial glossectomy

11. Dohlman’s procedure

12. Various neck flaps

13. Total laryngectomy

14. Pharyngolaryngectomy

15. Partial laryngectomy

16. Voice restoration procedures

17. Neck dissection

18. Thyroplasty

19. Rigid endoscopy (all)

20. Tracheostomy

21. Ranula excision

22. Submandibular gland excision

23. Superficial parotidectomy

24. Thyroglossal cyst excision

25. External carotid artery ligation

26. Neck lymph node biopsy

27. Excision of branchial cyst

28. Laryngo-fissure

29. Excision of pharyngeal pouch


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Privileges

Requested (To be

completed by the

applicant)



use) Under


30. LAUP

31. Throidectomy (all types)

32. A ryepiglottoplasty

33. Use of laser

a. CO2 (to assist in nasal surgery)

b. KTP (to assist in nasal surgery)

34. Use of navigation (to assist in larynx, head and neck surgery

35. Vocal folds (cords) injection with various materials (e.g fat, Teflon, etc)

36. Botilinum toxin injection in the circopharyngeal sphincter

CATEGORY V: AUDIOLOGY PROCEDURES

1. Video nystagmography and caloric testing

2. Rotatory chair test

3. Hearing aids assessment and programming

4. Auditory brain stem evoked response testing (with or without sedation)

5. Cochlear implant programming procedure

6. Auditory rehabilitation technique


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Privileges

Requested (To be

completed by the

applicant)



use) Under


7. Full audiological diagnostic procedure including: PT audiometric test battery, Tym panometry test battery, Otoacoustic emission testing, speech audiometry, and Behavioral hearing testing including VRA.

8. Particle reposition maneuver for BPPV

9. Vestibular rehabilitation exercise

10. Pure tone audiogram

11. Speech audiometry

12. Tympanometry

13. Acoustic reflex

14. Otoacoustic emission

15. Behavioural test

CATEGORY VI: Additional Privileges (not included above)

1.

2.

3.

4.

5.

6.


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Notes:

If additional privilege(s) are desired, please indicate this in the space provided above.

You must submit along with this application all necessary document(s) to support your request. If documentation is incomplete, your request will not be accepted.

By signing below, I acknowledge that I have read, understand, and agree to abide by QCHP standards

for privileging. I have requested only those privileges for which by education, training, current experience

and demonstrated performance I am qualified to perform and wish to exercise, and I understand that:

a) In exercising any clinical privileges granted, I am constrained by QCHP's policies and rules applicable generally and any applicable to the particular situation.

b) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the recognized policies and rules.

………………………………………………….. ………………………… Applicant’s signature (Stamp if any) Date …………………………………………………..….. ………………………… 1. Medical Director (of the facility the applicant Date

will perform surgeries in) Stamp & Signature ………………………………………………….. ………………………… 2. Medical Director (of the facility the applicant Date

will perform surgeries in) Stamp & Signature ………………………………………………….. ………………………… 3. Medical Director (of the facility the applicant Date

will perform surgeries in) Stamp & Signature


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For Committee use only

Evaluation Committee Chairman:

I have reviewed the requested clinical privileges and supporting documentation for the above-named

applicant and I have made the above-noted recommendation(s).

………………………………………………….. ………………………… Chairperson’s Stamp & signature Date Other Committee Members: ………………………………………………….. ………………………… 1) Name Date ………………………………………………….. ………………………… 1) Name Date

Surgical Privileges Form: ORL - HNS - QCHP | Home Privileges - Otolaryngology.pdf · Name of...

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