AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 and 1102. 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 P383530 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 P383532 P383534 P383536 P383538 P383540 P383542 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 P383544 P383546 P383548 P383550 P383552 P383554 P383556 P383558 P383560 P383562 P383564 P383566 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
P383568 P383570 P384148 P383572 P383574 P383576 P383578 P383580 P383582 P383584 P383586 P383588 P383590 P383592 P383594 P383596 P383598 P383600 P383602 P383604 P383606 P383608 P383891 P391302 P391305 P389488 P389490 P389492 P389494 P389496 P389498 P389500 P389502 P389504 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
Scrotum Requested Verified P389506 P389508 P389510 P389512 P389514 P389516 P389518 P389520 P389523 P389525 P389527 P389529 P389531 P389533 P389535 P389537 P389539 P388567 P389541 P389543 P389545 P388411 P389549 P389551 P389553 P389555 P389557 P389559 P389563 P389566 P389568 P389570 P389572 P389574 P389576 P389578 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
Ureter (Con t) Requested Verified P389580 P389582 P389584 P389586 P389588 P389590 P389592 P389594 P389596 P389598 P389600 P389602 P389604 P389606 P389608 P389610 P389612 P389614 P389616 P389620 P385441 P383614 P383616 P383618 P383620 P383622 P383624 P383626 P383628 P383630 P383632 P383634 P388802 P387317 P387323 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
Anesthesia procedures (Con t) Requested Verified P387333 Regional nerve block anesthesia P388406 Moderate sedation Other (Facility- or provider-specific privileges only): Requested Verified SIGNATURE OF APPLICANT DATE 5
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