KINGDOM OF SAUDI ARABIA MINISTRY OF HEALTH AL-QUNFUDAH GENERAL HOSPITAL

Ministry of Health
Al Qunfuda General Hospital

DEPARTMENT OF MAXILLO-FACIAL SURGERY

DELINEATION OF CLINICAL PRIVILEGES
______________________ :Name: _________________________________________ Date

Applicant: In the first column below, please check in the appropriate box for each privilege (listed below ( A Yes or No response must be entered for every item Department Head: Place your initials in the appropriate column (An entry must be made for (every item .N.B A copy of this privilege list will be given to the applicant The original privilege list will be kept in the Employee File .This list of Clinical Privileges is for review every two years
:To perform emergency lifesaving procedure are automatically granted to all staff physicians
Yes No

Clinical Privileges Requested

PRIVILEGES TO COVER OFF HOURS CALLS FOR ALL MAXILLO FACIAL SERVICES PROCEDURES ARE GRANTED .TO ALL STAFF IN MAXILLO FACIAL DEPARTMENT INVASIVE PROCEDURES WILL BE PERFORMED ONLY BY THOSE SO SPECIFICALLY PRIVILEGED MAXILLO FACIAL SURGERY

Granted

Granted with Supervision

Denied

CATEGORY I

Simple Extraction Surgical Extraction Surgical exposure of unerupted tooth Apisectomy Closure of oroantral communication Splinting of displaced teeth by arch bar Splinting of displaced teeth by direct wiring Splinting of displaced teeth by composite split

KINGDOM OF SAUDI ARABIA MINISTRY OF HEALTH AL-QUNFUDAH GENERAL HOSPITAL

Ministry of Health
Al Qunfuda General Hospital

Biopsy Incisional Biopsy Aspiration Biopsy Simple suturing Upper or lower arch bar I & D of oral Abscess Excisional Biopsy Complicated Suturing Simple scar revision Fistulectomy Frenectomy Alveoloplasty Maxillary tuberosity reduction Cyst marsupalization Cyst enucleation Closed reduction IMF Closed reduction of Zygomatic Fracture I & D of facial space infection Complicated scar revision Cryosurgery Sublingual Adeninoectomy Ridge Augmentation Alloplastic Graft Soft tissue graft Vestibuloplasty Atherocenthesis Alveolar distraction

CATEGORY II

CATEGORY III

KINGDOM OF SAUDI ARABIA MINISTRY OF HEALTH AL-QUNFUDAH GENERAL HOSPITAL

Ministry of Health
Al Qunfuda General Hospital

Trauma ORIF of mandibular fracture ORIF of maxillary fracture ORIF ZMC fracture ORIF of frontal bone fracture Coronoidectomy Dry closure of cleft lip and plate Closure of oroantral fistula Grafting of cleft alveolus 2nd Closure of cleft and palate Tumour resection Superficial parodectomy Submandibular adeninoectomy Neck dissection Local flaps for pathological defects Microvascular graft Preprosthetic surgery Sinus Lift Autogenous bone graft Mental nerve relocation Tibial graft Anterior and posterior iliac crest graft Rib graft Calverium graft TMJ Surgery Gap arthroplasty with graft Condylectomy

CATEGORY IV

KINGDOM OF SAUDI ARABIA MINISTRY OF HEALTH AL-QUNFUDAH GENERAL HOSPITAL

Ministry of Health
Al Qunfuda General Hospital

Requesting Physician Recommended Approved by

______________________________________________________ Name /Signature of Requesting Physician Date ______________________________________________________ Head of Maxillo-Facial Surgery Department Date ______________________________________________________ Chairperson Credentialing & Privileging Committee Date ______________________________________________________ Director of Medical Services Date ______________________________________________________ Assistant Director for Professional Affairs Date ______________________________________________________ Director Hospital Date