Surgical Privileges Form: ORL - HNS
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1 Surgical Form: ORL - HNS Clinical Request Applicant s Name:. License No. (If Any):... Date:... Scope of Practice:. Facility:.. 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 Page 1 of 10
2 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 Page 2 of 10
3 19. Middle fossa approach 20. Posterior fossa approach 21. Ear canal osteoma excision 22. Use of laser a. CO2 (to assist in otological b. KTP (to assist in otological 23. Use of navigation (to assist in ontological 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 (nonendoscopic) 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 Page 3 of 10
4 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 Page 4 of 10
5 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 d. KTP (to assist in nasal 29. Use of navigation (to assist in nasal 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 Page 5 of 10
6 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 Page 6 of 10
7 30. LAUP 31. Throidectomy (all types) 32. A ryepiglottoplasty 33. Use of laser a. CO2 (to assist in nasal b. KTP (to assist in nasal 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 Page 7 of 10
8 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 (not included above) Page 8 of 10
9 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: 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 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 Page 9 of 10
10 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 Page 10 of 10
Surgical Privileges Form: ORL - HNS
Surgical Privileges Form: ORL - HNS Clinical Privileges Request Applicant s Name:. No. (If Any):... Date:... Scope of Practice:. License Facility:.. Place of Work:. CATEGORY I: OTOLOGY PROCEDURES Privileges
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