LIST OF CLINICAL PRIVILEGES UROLOGY
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1 AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 and PRINCIPAL PURPOSE: To define the scope and limits of practice for individual providers. Privileges are based on evaluation of the individual s credentials and performance. ROUTINE USE: Information on this form may be released to government boards or agencies, or to professional societies or organizations, if needed to license or monitor professional standards of health care providers. It may also be released to civilian medical institutions or organizations where the provider is applying for staff privileges during or after separating from the Air Force. DISCLOSURE IS VOLUNTARY: However, failure to provide information may result in the limitation or termination of clinical privileges INSTRUCTIONS APPLICANT: In Part I, enter Code 1, 2, or 4 in each REQUESTED block for every privilege listed. This is to reflect your current capability. Sign and date the form and forward to your Clinical Supervisor CLINICAL SUPERVISOR: In Part I, using the facility master privileges list, enter Code 1, 2, or 4 in in each VERIFIED block in answer to each requested privilege. In Part II, check appropriate block either to recommend approval, to recommend approval with modification, or to recommend disapproval. Sign and date the form and forward the form to the Credentials Office. CODES: 1. Fully competent within defined scope of practice. 2. Supervision required. (Unlicensed/uncertified or lacks current relevant clinical experience. 3. Not approved due to lack of facility support. (Reference facility master Strawman. Use of this code is reserved for the Credentials Function.) 4. Not requested/not approved due to lack of expertise or proficiency, or due to physical disability or limitation. CHANGES: Any change to a verified/approved privileges list must be made in accordance with Service specific credentialing and privileging policy NAME OF APPLICANT LIST OF CLINICAL PRIVILEGES UROLOGY NAME OF MEDICAL FACILITY I Scope Requested Verified P The scope of privileges in Urology include the evaluation, diagnosis, treatment and consultation for patients of all ages presenting with congenital or acquired conditions of the genitourinary system, contiguous structures, and the adrenal gland. Urologists provide medical and pre-, intra-, and post-operative management of these conditions. Physicians may admit to the facility and may provide care to patients in the intensive care setting in accordance with MTF policies. Urologists may also assess, stabilize, and determine the disposition of patients with emergent conditions in accordance with medical staff policy. Diagnosis and Management (D&M) Requested Verified P P P P P P Male family planning and infertility Urolithiasis and metabolic disorders associated with urolithiasis Ultrasound evaluation and interpretation of genitourinary tract Use of image guidance for diagnostic and therapeutic procedures Perform and interpret urodynamic studies Perform and interpret fluoroscopic studies of the genital and urinary tracts Procedures P P P P P P P P P P P P General Requested Verified Incision and drainage of the retroperitoneum, perineum, genitourinary tract and external genitalia Biopsy/excision/fulgaration of lesions of the retroperitoneum, urinary and genital organs Exposure, resection and repair of injuries to and removal of foreign bodies from the abdomen, retroperitoneum, perineum and urinary and genital organs Open or endoscopic removal, manipulation or destruction of stones of the urinary tract Closure of fistula involving the urinary tract Repair hernia with or without prosthetic material Harvest of skin, buccal mucosa, muscle, fascia and tunica vaginalis for flaps and grafts Percutaneous access to any structure of the genitourinary tract for diagnosis or treatment Instillation or injection of therapeutic agents to the genital or urinary tract Care of surgical wounds including washout, grafting, debridement, wound vac and closure Insertion of electroneurostimulating device for treatment of urinary/fecal symptoms Neurectomy 1
2 P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P General Requested Verified Trauma - Exposure, resection and/or repair of traumatic injuries of the genitourinary system and injuries occurring in conjunction with genitourinary trauma (i.e., repair of bowel, spleen, liver) Extracorporeal shock wave lithotripsy (ESWL) Hysterectomy Techniques Requested Verified Laparoscopic approach for any urological procedure Robotic assisted laparoscopic approach for any urological procedure Utilization of laser, mechanical, electrical, pneumatic thermal or other energy for the excision, coagulation, vaporization, fulgaration, ablation and/or repair of tissues and destruction of stones Microsurgical techniques for urological procedures Urinary Diversion Requested Verified Cutaneous vesicostomy, ureterostomy, pyelostomy, urethrostomy and closure Enteric or colonic urinary conduit Continent catheterizeable stoma Neobladder or continent urinary diversion Ureterosigmoidostomy Penis Requested Verified Amputation, partial or complete Circumcision Aspiration and irrigation of corpora Insertion of penile prosthesis Straightening of chordee Insertion or surgical treatment for Peyronie's disease Repair of continent epispadias and hypospadias Creation of shunt for priapism Repair of penoscrotal transposition Vascular repair for impotence Phalloplasty Neophallus Repair of epispadias with incontinence Urethra Requested Verified Meatotomy/Meatoplasty Transurethral bladder catheterization Urethrectomy Repair of urethral prolapse Diverticulectomy Urethroplasty Insertion urethral stent Operation for incontinence with or without prosthesis, by vaginal, transabdominal or perineal approach Insertion of artificial urinary sphincter 2
3 Scrotum Requested Verified P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P Resection of scrotum Plastic revision of scrotum Puncture of hydrocele for drainage or instilling medication Hydrocelectomy Testis, Spermatic cord, and Seminal Vesicles Requested Verified Orchiectomy Treatment of testicular torsion Orchiopexy Insertion of testicular prosthesis Sperm harvest Vasotomy and cannulation, with or without incision for treatment, vasograms, seminal vesiculograms or epididymograms Vasovasostomy Epididymovasostomy Epididymectomy Varicocele treatment Lysis of cremasteric muscle Spermatocelectomy Vesiculectomy Vasectomy Prostate Requested Verified Simple prostatectomy by abdominal or perineal approach Radical prostatectomy by abdominal or perineal approach Interstitial brachytherapy Urinary bladder Requested Verified Suprapubic bladder aspiration Surgical treatment of urachal anomaly Cystectomy, partial or complete Bladder diverticulectomy Enterocystoplasty Anterior pelvic exenteration Reconstruction for vesical exstrophy Excision of ureterocele Ureter Requested Verified Ureterotomy Ureterectomy Ureteroplasty Ureterolysis Pyelo or Calycoureterostomy Transureteroureterostomy Replacement of ureter with enteric segment 3
4 Ureter (Con t) Requested Verified P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P Ureteroneocystostomy Pyeloureteroplasty Kidney Requested Verified Nephrostomy Excision or unroofing of cyst of the kidney Nephropexy Nephrectomy, partial or complete Nephrectomy, living donor Nephrectomy with vena cava thrombectomy Nephroureterectomy Harvest of cadaver kidneys Auto transplantation Homotransplantation Adrenal gland Requested Verified Adrenalectomy, partial or complete Retroperitoneum/lymphatic system Requested Verified Retroperitoneal lymphadenectomy Pelvic lymphadenectomy Inguinal lymphadenectomy, deep and superficial Female urology Requested Verified Clitoroplasty and vaginoplasty Cystocele repair Rectocele repair Transvaginal, transabdominal or transperineal repair of pelvic organ prolapse with or without prosthetics Repair of enterocele Endoscopic procedures Requested Verified Endoscopic catheterization/stent Internal urethrotomy Urethral calibration/dilation/incision Hydrodistension/lavage/irrigation of bladder Endoscopic treatment of ureterocele Transurethral resection of bladder tumor Transurethral resection/incision of bladder neck Transurethral resection/incision of prostate Transurethral resection/incision of urethral valves Endoscopic incision/dilation/treatment of ureteral abnormalities Ureteroscopy Cystorurethroscopy with or without biopsy Anesthesia procedures Requested Verified Topical and local infiltration anesthesia Peripheral nerve block anesthesia 4
5 Anesthesia procedures (Con t) Requested Verified P Regional nerve block anesthesia P Moderate sedation Other (Facility- or provider-specific privileges only): Requested Verified SIGNATURE OF APPLICANT DATE 5
6 II CLINICAL SUPERVISOR S RECOMMENDATION RECOMMEND APPROVAL RECOMMEND APPROVAL WITH MODIFICATION RECOMMEND DISAPPROVAL (Specify below) (Specify below) STATEMENT: CLINICAL SUPERVISOR SIGNATURE CLINICAL SUPERVISOR PRINTED NAME OR STAMP DATE 6
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