CLEVELAND AMBULATORY CENTER DELINEATION OF CLINICAL PRIVILEGES Applicant’s Signature Date

The granting, reviewing and changing of clinical privileges will be in accordance with the Medical Staff Bylaws. Assignment of such clinical privileges must be based upon education, clinical training, demonstrated skills and capacity to manage procedurally related complications.

Indicate procedures for which you do and do not wish to be credentialed. Return this form with your Application.

Recommendation by Procedures Credentialing Request QM Committee

Yes No Yes No

Hernia hydrocele repair

Repair inguinal hernia w/orchiectomy

Repair inguinal hernia w/excision of hydrocele

Repair inguinal hernia, recurrent

Repair inguinal hernia, sliding

Repair ventral hernia

Repair ventral hernia, recurrent

Repair unbilical hernia, age 5 or over

Drain perineal abscess

Cath or stent

Injection for pyelography thru cath

Injection procedure for pyelography

Change tube

Renal thru established nephrostomy

Renal endoscopy w/fulguration and/or excision

Injection ureterography thru cath

Injection vis ileal conduit

Ureteral endoscopy w/ureteral cath

Ureteral endoscopy w/biopsy

Fulguration

Urethrotomy pendulous

Urethrotomy perineal urethra

Meatotomy

Meatotomy infant

Drainage deep periurethral abscess

Excision or fulguration carcinoma urethra

Excision urethral diverticulum female

Excision urethral diverticulum male

Marsup

Excision urethral caruncle

Excision urethral prolapse

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Recommendation by Procedures Credentialing Request QM Committee

Yes No Yes No

First stage

Second stage urethroplasty

Urethroplasty 1 stage

Urethroplasty 2 stage

Urethroplasty scrotal perineal

Urethroplasty female

Incontinence procedure male

Urethromeatoplasty w/mucosal adhesions

Urethromeatoplasty w/partial excision

Urethrorrhaphy female

Urethrorrhaphy perineal

Urethrorrhaphy prostate

Close urethrostomy fistula

Urethral dilatation male sound

Urethral dilatation sound-

Urethral dilatation male filiforms & followers

Urethral dilatation female

Dilatation female urethral w/anesthesia

Dorsal slit

Biopsy deep

Excision of penile plaque

Removal foreign body from deep penis

Amputation penis partial

Ureteral endoscopy w/fulguration, incision

Ureteral endoscopy w/removal foreign body

Ureteral endoscopy thru ureterotomy

Aspiration bladder trochar intracath

Punch cystostomy

Injection procedure for

Injection procedure for retrograde urethrocysto

Change of cystostomy tube

Cystorrhaphy complex

Cystoscopy

Cysto w/ureteral

Brush biopsy renal pelvis

Cystourethroscopy w/ejaculation duct

Cysto and biopsy

Cysto with fulguration

Cystourethroscopy w/fulguration minor

Page 2 of 5 MS2O DELINEATION OF CLINICAL PRIVILEGES - Urology - (continued)

Recommendation by Procedures Credentialing Request QM Committee

Yes No Yes No

Cysto & dilation bladder

Cysto & inter urethrotomy female

Cysto & inter urethrotomy male

Direct vision cold urethrotomy

Cystourethroscopy w/steroid injection

Cystourethroscopy urethral syndrome

Cysto w/resection

Cysto incompetent bladder diverticulum

Cysto removal of foreign body/DJ stent

Cystourethroscopy w/removal foreign body or calculus

Lithopaxy small

Lithopaxy large

Cysto stone basket extraction

Cysto stone basket manipulation

Cysto insert DJ stent

Ureteroscopy complete and dilatation

Ureteroscopy w/stone extraction

Ureteroscopy w/ultra

Ureteroscopy w/biopsy/fulguration

Cysto imcompetent bladder neck

Amputation penis complete

Circumcision, clamp except newborn

Circumcision, newborn

Circumcision surgery except newborn

Injection Peyronie's expose plaque

Irrigation corpora cavernosa/priaprism

Injection procedure for corpora cavernosopraphy

Plastic operation of penis, injury

Biopsy of testis, incision unilateral

Biopsy of testis, incision bilateral

Excision local lesion testis

Orchiectomy, unilateral

Orchiectomy radical inguinal approach

Orchidopexy unilateral

Orchidopexy bilateral

Repair testicular injury

Transposition of testis to thigh

Incision & drainage of epididymis

Excision local lesion epididymis

Page 3 of 5 MS2O DELINEATION OF CLINICAL PRIVILEGES - Urology - (continued)

Recommendation by Procedures Credentialing Request QM Committee

Yes No Yes No

Epididymectomy unilateral

Epididymectomy bilateral

Epididymovasostomy, unilateral

Epididymovasostomy, micro bilateral

Excision hydrocele unilateral

Excision hydrocele bilateral

Repair hydrocele bottletype

Removal of foreign body in

Resection of scrotum

Scrotoplasty, simple

Scrotoplasty, complicated

Vasovasostomy, unilateral

Excision hydrocele sperm cord unilateral

Excision lesion sperm cord

Excision varicocele or ligation of sperm cord

Ligation internal sperm vein

Excision varicocele of sperm cord w/hernia

Excision Mullerian duct cyst

Needle biopsy of prostate

Biopsy prostate incisional

Prostatotomy simple

Incision & drainage of perineal abscess

Marsupialization of Bartholins

Destruction of lesions, vulva extensive

Excision of Bartholins gland

Colpocentesis

Biopsy vaginal mucosa, extensive

Excision of vaginal septum

Injection procedure for retrograde urethroscopy

Interpretation of x-rays taken within the facility

Establish nephrostomy tubes

Extracorporeal Shockwave Lithotripsy

Excision Spermacele

For Administrative Purposes Only

Clinical privileges recommendations approved by Governing Body: .______Facility President Date

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