DELINEATION OF CLINICAL PRIVILEGES

CONSULTANT-CTVS
Photograph

Name: , Date:

Applicant: In the first columns below, place a check in the appropriate box for each privilege listed below.
A yes or no response must be entered for every item.
Chairperson: Place your initials in the appropriate column. An entry must be made for every item.

Granted with
Yes No Clinical Privilege Requested Granted Supervision Denied

To perform emergency lifesaving procedures are automatically granted

to all staff physicians:
Privileges Are Requested To The Following Procedures/Interventions:

Open Heart Surgeries

  CABG (By pass surgery)
  Mitral / Aortic Valve Replacement
  ASD Repairs
  Myxoma / Aneurysmechtomy
Minimal invasive cardiac surgery
  CABG (By pass surgery) - MIDCAB / THORACAB
  Port Access Cardiac Surgery- MVR / AVR / ASD Closure / LA Myxoma
Removal / VSD Closure / L-V Aneurysmorhyphy
  Redo Cases Lateral MIDCABS
  Port Access Redo Mitral Valve Surgery
Pediatric surgery
  Non Complex ASD / VSD /TOF/ TAPVC/ TCPC/Fontan /
  Senning / ASO / Bidirectional Glenn / DSO / AV canal Repair /
  Conduit repair
  Complex ASD /VSD /Conduit Repair
  PDA Ligation
  BT Shunt
Vascular Surgery
  Peripheral vascular Procedure/Carotid Endartectomy
  Aortic Arch replacement/Descending thoracic Aorta /
  Thoraco – abdominal aneurysm repair/ Aorto –bifemoral bypass
  Abdomino-Aortic Aneurism

Congenital Heart disease intervention

  Balloon Atrial Septostomy
 Granted with
Yes No Clinical Privilege Requested Granted Supervision Denied

  PDA Coil Occlusion

  ASD/VSD/PFO/FFD Device Closure
  Valvuloplasty / Others
  Infant Valvuloplasty / Others
  PDA Device closure
Others
  Septal Ablation
  IVC Filter
  IABP (Balloon Pump)
  Pericardial Tapping
  Pleural Tapping
  Coronary Bypass Surgery-post Angioplasty

  Coronary Balloon Angioplasty

  Balloon angioplasty with Valvotomy

  Open Heart Procedures

  Total Correction of Tetralogy of Fallot

  RSUV Correction

  TAPVC Correction

  Open ASD VSD

  Open Pulmonary Valvotomy

  Open Aortic Valvotomy

  Balock Taussig Operation

  Mitral Valvotomy

  Mitral Valve Replacement

  Aortic ValveReplacement

  Double Valve Replacement

  Closed Valvotomy

  Coarctation-Arota Repair of Balock Taussing Shunt

  Patent Ductus Arteriousus

  Mitral Valvotomy (Open)

  Pericardiostomy

  Pericardiectomy

  Pericardio Centrosis

  Permanent Pacemaker Implantation

  Temporary Pacemaker Implantation

 Granted with
Yes No Clinical Privilege Requested Granted Supervision Denied

  Test of Pacemaker

  Embolectomy

  Aneurysm Resection & Grafting

  Thoracocentesis

  Thorachostomy

  Exploratory Thorocotomy

  Aorta-Femoral Bypass

  Removal of Foreign Body from Trachea or Oesophagus

  Rib Resection & Drainage

  Mediastinal Tumour

  Thymectomy

  Partial Pericardectomy

  Removal Tumours of Chest Wall

Others (Please Specify )

I hereby certify that I am sound by physical & mental health

__________________________________ _______________

Signature of Applicant Regn Number Date

Do not write below this line

RECOMMENDED BY:

______________________________________
MEDICAL SUPERINTENDENT

DATE:______________________
 APPROVED BY:

_____________________________________________________
Chairman, Credentialing & Privileging Committee

DATE:______________________