Form 0917-0009-6 0917-0009-6, Surgical Privileges Request Form

Circular Appendix 95–16–C.3 (04/10)
Page 7 of 7

Surgical PRIVILEGES REQUEST FORM

INTRODUCTION

This Surgical Privileges Request Form must be accompanied or preceded by a completed application for medical staff appointment, including the necessary supporting documents. Many clinical privileges pertinent to the practice of surgery and surgical specialties are listed below. This list contains both outpatient and inpatient items. The request for privileges must reflect both the applicant’s and the facility/staff’s ability to carry out or support the various functions. Documentation of training and/or experience in performing various surgical procedures must accompany this request. Any additional privileges may be requested on the Surgical Privileges Request Form or may be presented in an attached list and referenced on this form under “other.”

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item whether you are requesting limited or full privileges. Limited means that the applicant may function in the area of the stated clinical privileges only under the direct supervision of a provider holding full privileges. Full means that the applicant is entitled to function independently, following standards consistent with the medical community at large; in general, full surgical privileges require the completion of an accredited surgical residency. Be sure to sign the request as indicated on page 7.

Discipline-specific supervisor or consultant: Indicate your recommendation for each requested clinical privilege by placing a check mark in the appropriate location for either full, limited, or not recommended (N.R.). Please explain any recommended limitations or denial of privileges on an attached sheet. Your recommendations are considered by the governing body when granting or not granting privileges.

I. GENERAL SURGERY

A. Skin	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Skin tumors
2. Split thickness grafts
3. Wolfe grafts
4. Pedicle grafts
5. Skin lacerations
6. Extensive burns
7. Pilonidal cyst

B. Head and Neck	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Parotid gland surgery
2. Lip and tongue surgery
3. Ranula
4. Epulis
5. Resection of jaw
6. Thyroglossal ducts
7. Branchial clefts
8. Pharyngo-esoph. diverticulum
9. Thyroidectomy
10. Phrenic nerve

C. Abdominal and Rectal	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Paracentesis
2. Gastroscopy
3. Closure perforated ulcer
4. Other gastric surgery
5. Ramstedt Pyloromyotomy
6. Gallbladder and common duct surgery
7. Pancreatic surgery
8. Splenectomy
9. Small and large bowel surgery
10. Appendectomy
11. Abdomino-perineal resection
12. Abdominal exploratory after workup
13. I & D of intra-abdominal abscess
14. Traumatic laparotomy
15. Simple inguinal hernia
16. Strangulated or recurrent hernia
17. Ventral or femoral hernia
18. Proctosigmoidoscopy
19. Anoscopy
20. Hemorrhoidectomy
21. I & D Perirectal Abscess
22. Fistula in ano
23. Liver biopsy, open
24. Liver biopsy, closed

D. Breast and Thoracic	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Breast biopsy
2. Simple & radical mastectomy
3. Thoracentesis & closed drainage
4. Rib resection for empyema
5. Thoracoplasty
6. Intrathoracic surgery
7. Surgery of diaphragm

E. Other	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Hand infections (major)
2. Hand infections (minor)
3. Other (Specify):

II. Vascular Surgery	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Vein ligation and stripping
B. Major vascular surgery
C. Arterial grafts
D. Other (Specify):

III. OPHTHALMOLOGIC	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Chalazion
B. Pterygium
C. Enucleation
D. I & D abscess of lid
E. Corneal laceration
F. Plastic on lids
G. Cataract
H. Squint
I. Dacryocystectomy
J. Dacryocystorhinostomy
K. Glaucoma
L. Retinal detachment
M. Laser therapy
N. Other (Specify):

IV. Ear, Nose, and Throat (ENT)	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Tracheostomy
B. I & D abscess or hematoma of canal or auricle
C. Laceration repair of nose or auricle
D. Foreign body removal from nose or ear
E. Complex laceration repair of nose/ear/face/neck
F. Tonsillectomy, adenoidectomy
G. Biopsy lesions of nose or auricle
H. Laryngoscopy
I. Nasal packing
J. Nasal fracture reduction
K. Reconstructive surgery of congenital deformities, including facial abnormalities (i.e., cleft lip and palate)
L. Split thickness skin graft
M. Full thickness skin graft
N. Bone, cartilage, and alloplastic grafts
O. Blepharoplasty
P. Rotation flaps
Q. Myringotomy
R. Myringotomy with tube insertion
S. Excision of rhinophyma
T. Tympanotomy, tympanoplasty
U. Mastoidectomy, simple
V. Middle ear—removal of polyps, stapes mobilization
W. Otoplasty
X. Stapedectomy
Y. Rhinoplasty, septoplasty
Z. Maxillo-facial injury repairs, including fractures
AA. Excision of nasal mucosa, turbinates, polyps
BB. Sinusotomy
CC. Radical mastoidectomy
DD. Palatoplasty
EE. Lip resection
FF. Other (Specify):

V. Urological Surgery	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Nephrectomy
B. Pyelostomy
C. Ureterotomy
D. Cystostomy
E. Suprapubic prostatic resection
F. Other suprapubic bladder surgery
G. Cystectomy
H. Cystoscopy and retrograde pyelogram
I. Transurethral cysto. and prostate surgery
J. Hydrocele, spermatocele, varicocele
K. Vasectomy
L. Testicular surgery
M. Circumcision & meatotomy
N. Major surgery of penis
O. Other (Specify):

Surgical PRIVILEGES REQUEST FORM

1. I hereby request the clinical privileges as indicated on the forms attached.

Applicant Date

2. I hereby recommend the clinical privileges as indicated.

Supervisor/Consultant Date

3. As Chairperson of the Medical Staff Executive Committee, I hereby recommend the clinical privileges: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Clinical Director Date

4. I hereby recommend the applicant for clinical privileges.

Service Unit Director Date

5. Privileges are hereby granted: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Chairperson of the Date

Governing Body

Estimated Average Burden Time per Response

Public reporting burden for this collection of information is estimated to average 60 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer, Indian Health Service, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852, ATTN: PRA (0917–0009). Please do not send this form to this address.