Surgical Form: Clinical Request General surgery Applicant s Name:. License No. (If Any):... Scope of Practice:. Facility:.. Date:.. CATEGORY I: Basic Surgical skills 1. Insertion of Intravenous Line 2. Insertion of Urinary Cater 3. Insertion of Nasogastric tube 4. Insertion of Oropharyngeal airway 5. History taking and Physical Examination 6. Admitting patients 7. Wound Dressing CATEGORY II: Skin & subcutaneous Surgery 1. Excision of Sebaceous cyst 2. Excision of Lipoma 3. Excision of Ingrown nail 4. Excision of skin nodule / wart 5. Incision and drainage of abscess 6. Aspiration of skin swelling ( FNA ) 7. Excision of Pilonidal Sinus 8. Ray`s mid- metatarsal Amputation of toe 9. Debridement of Diabetic Foot CATORGY III: Neck Surgery 1. Excision of Lymph node 2. Excision of Brancheal cyst 3. Excision of Thyroglossal cyst/ Fistula 4. Thyroid FNA 5. Thyroidectomy 6. Parotidectomy 7. Submandibular Sialadenectomy 8. Cervical Sympactomy 9. Modified Radical neck Dissection
CATEGORY IV: Gastroesophageal Surgery 1. Esophagectomy 2. Vasoligation of Esophageal & Gastric Varices 3. Esophageal Transection 4. Radical Gastrectomy 5. Partial Gastrectomy for Benign lesions 6. Laparoscopic Gastrectomy 7. Gastrojejunostomy 8. Laparoscopic Gastrojejunostomy 9. Vagotomy Gastrojejunostomy 10. Laparoscopic Fundoplication 11. Laparoscopic Repair of Diaphragmatic Hernia 12. Laparoscopic closure of Perforated Duodenal Ulcer 13. Laparoscopic Hellers Myotomy 14. Cystogastrostomy CATEGORY V: Bariatric Surgery 1. Laparoscopic Sleeve Gastrectomy 2. Laparoscopic insertion/ removal of Gastric Band 3. Laparoscopic Gastric Bypass 4. Laparoscopic Duodenal Switch 5. Endoscopic Gastric Balloon Insertion CATEGORY VI: Spleen & Lymph Nodes 1. Splenectomy for trauma 2. Laparoscopic Splenectomy 3. Laparoscopic Peritoneal biopsy 4. Laparoscopic Omentectomy 5. Laparoscopic Lymph Node Biopsy 6. Laparoscopic Adhesiolysis Page 2 of 7
CATEGORY VII: Hepatobiliary 1. Laparoscopic Cholecystectomy 2. Laparoscopic Common bile duct exploration 3. Laparoscopic drainage of liver abscess 4. Marsipulization of Hydatid cyst of Liver 5. Partial Hepatectomy 6. Laparoscopic Hepatic sigmentectomy 7. Hepaticojejunostomy 8. Choleduchoduodenostomy 9. Carcinoma of Gall Bladder 10. Carcinoma of Billiary tree CATEGORY VIII: Pancreas 1. Distal Pancreatectomy 2. Laparoscopic distal Pancreatectomy 3. Pancreatecoduodenectomy (Whipple) 4. Pancreaticojejunostomy ( Puestow ) CATEGORY IX: Small Bowel 1. Open & Laparoscopic Appendectomy 2. Laparoscopic Mickle`s Diverticulectomy 3. Small Bowel Resection & Anastomosis 4. Cystojejunostomy 5. Laparotomy and Exploration 6. Laparoscopic Exploration Page 3 of 7
CATEGORY X: Colorectal Surgery 1. Right hemicolectomy 2. Left hemicolectomy 3. Sigmoid Colectomy 4. Hartmann`s Procedure 5. Reversal of Hartmann 6. Anterior Resection 7. Total Colectomy 8. Laparoscopic right hemicolectomy 9. Laparoscopic Left hemicolectomy 10. Laparoscopic Sigmoid Colectomy 11. Laparoscopic Anterior Resection 12. Laparoscopic Total Colectomy 13. Laparoscopic Rectopexy 14. Haemorrhoidectomy 15. Fistulectomy / Fistulotomy 16. Fissurectomy / Sphincterotomy 17. Sphincteroplasty 18. Ileal pouch and ilio-anal Category XI: Breast 1. FNA / Core Biopsy 2. Lumpectomy for benign conditions 3. Lumpectomy / Axillary Clearance 4. Sentinel Lymph Node Dissection 5. Mastectomy CATEGORY XII: Adrenals 1. Adrenalectomy 2. Laparoscopic Adrenalectomy Category XII: Hernia 1. Open repair of inguinal Hernia 2. Open repair of femoral Hernia 3. Open repair of Epigastric Hernia 4. Open repair of Paraumbilical Hernia 5. Open repair of Lumbar Hernia Page 4 of 7
6. Open repair of Incisional Hernia 7. Repair of Large Hernia with Dermolipectomy 8. Open repair of hernia with Anterior Component separation 9. Open repair of hernia with Posterior Component Separation 10. Laparoscopic repair of inguinal Hernia 11. Laparoscopic repair of femoral Hernia 12. Laparoscopic repair of Epigastric Hernia 13. Laparoscopic repair of Paraumbilical Hernia 14. Laparoscopic repair of Lumbar Hernia 15. Laparoscopic repair of Incisional Hernia 16. Laparoscopic repair of hernia with Anterior Component separation Category XIII: Additional 1. 2. 3. 4. 5. es: If additional privilege(s) are desired, please indicate this in 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. Page 5 of 7
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 particular situation. b) Any restriction on clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by recognized policies and rules... Applicant s signature (Stamp if any) Date.... 1. Medical Director (of facility applicant Date will perform surgeries in) Stamp & Signature.. 2. Medical Director (of facility applicant Date will perform surgeries in) Stamp & Signature.. 3. Medical Director (of facility applicant Date will perform surgeries in) Stamp & Signature Page 6 of 7
For Committee use only Evaluation Committee Chairman: I have reviewed requested clinical privileges and supporting documentation for above-named applicant and I have made above-noted recommendation(s)... Chairperson s Stamp & signature Date Or Committee Members:.. 1) Name Date.. 1) Name Date Page 7 of 7