Surgical Privileges Form: "Neurosurgery" Clinical Privileges Request. Requested (To be completed by the applicant) Not Recommended (For committee use)

Transcription

1 Surgical Form: Clinical Request "Neurosurgery" Applicant s Name:. License No. (If Any):... Date:... Scope of Practice:. Facility:.. Place of Work:. the applicant) CATEGORY I: Core : 1. Interpretation of laboratory tests 2. Insertion of urinary catheters 3. Peripheral intravenous catheter insertion 4. Nasogastric tube insertion 5. Oropharyngeal airway insertion 6. Prescribing oxygen therapy CATEGORY II: Admitting : 1. Admitting patients under own name 2. Admitting patients under the Consultant/Attending's name 3. Admission history and physical exam CATEGORY III: Specific A. Cranial Procedures 1. Surgery for cranial trauma 2. Surgery for convexity/superficial brain tumors 3. Surgery for deep and complex skull base tumors 4. Surgery for posterior fossa brain tumors 5. Surgery for cerebral aneurysm or Arterio Venous Malformation and other vascular lesions

2 6. Posterior fossa-microvascular decompression procedures 7. Trans sphenoidal surgery for sellar / para /supra sellar lesions and Repair of Cerebro spinal fluid leak 8. Steriotactic guided surgery for brain lesions including biopsy and microcraniotomy 9. Robot assisted surgery for brain biopsy and resection 10. Cranial endoscopic procedures including 3rd ventriculostomy and others 11. Insertion of depth electrodes /subdural mats/electrodes for epilepsy 12. Ablative surgery for epilepsy the applicant) 13. Steriotactic deep brain stumation 14. Steriotactic radiosurgery B. Spinal Procedures / Surgeries 1. Epidural steroid injections for pain 2. Insertion of subarachnoid or epidural catheter with reservoir or pump for drug infusion 3. Lumbar subarachnoid-peritoneal shunt 4. Endoscopic Minimally invasive Surgery 5. Cordotomy, rhizotomy and spinal cord stimulators for the relief of pain 6. Radiofrequency ablation 7. Selective blocks for pain medicine, stellate ganglion blocks Page 2 of 6

3 8. Spinal cord surgery for decompression of spinal cord or spinal canal, for intramedullary lesion, intradural extramedullary lesion, rhizotomy, cordotomy, dorsal root entry zone lesion, tethered spinal cord or other congenital anomalies (diastematomyelia) 9. Laminectomies, laminotomies and fixation and reconstructive procedures of spine and its contents including instrumentation completed by the applicant) 10. Surgery for intervertebral disc disease 11. Surgery on the sympathetic nervous system 12. Percutaneous vertebroplasty Balloon kyphoplasty 13. Percutaneous neucleoplasty for disc diesease C. Peripheral Nerve Procedures 1. Peripheral nerve procedures, including decompressive procedures and reconstructive procedures on the peripheral nerves 2. Nerve blocks 3. Nerve biopsy 4. Muscle biopsy Page 3 of 6

4 the applicant) D. Other Procedures 1. Intra Cranial Pressure insertion 2. Lumbar Drain 3. External Ventricular Drain 4. Lumbar puncture, cisternal puncture, ventricular tap, subdural tap 5. Shunts: ventriculoperitoneal, ventriculoatrial, ventriculopleural, subdural peritoneal, lumbar subarachnoid/peritoneal (or other cavity) E. Surgery for Congenital Anomalies 1. Surgery for craniosynostosis 2. Surgery for Chairi malformation 3. Management of congenital anomalies, such as encephalocele, meningocele, myelomeningocele F. Endovascular Procedures 1. Performing and interpreting diagnostic imaging studies related to the vasculature of the Central Nervous System, head, neck, and spine. 2. Participating in short-term and longterm postprocedure follow-up care, including neurointensive care 3. Transarterial and transvenous catheterization of the arteries and veins of the Central Nervous System, skull, face, neck, and spine. Page 4 of 6

5 the applicant) 4. Embolization of arterial and venous vascular lesions of the central nervous system and the vessels supplying the structures of the Central Nervous System, skull, face, neck, and spine with embolic agents including but not limited to coils, glue, and particles. 5. Intracranial arterial stent placement. 6. Spinal angiography 7. Intra-arterial and intra-venous injection of thrombolytic agents for clot lysis therapy in vessels supplying or draining the Central Nervous System or its related bony and soft tissue structures. 8. Intra-arterial and intra-venous injection of non-thrombolytic agents for diagnostic testing and treatment of disease in vessels supplying or draining the CNS or its related bony and soft tissue structures. CATEGORY IV: Additional : es: 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: Page 5 of 6

6 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 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 Evaluation Committee Chairman: For Committee use only 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 Page 6 of 6