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DEPARTMENT DENTISTRY, SECTION OF ORAL AND MAXILLOFACIAL ...

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DEPARTMENT DENTISTRY, SECTION OF ORAL AND MAXILLOFACIAL ...

  1. 1. DEPARTMENT DENTISTRY, SECTION OF ORAL AND MAXILLOFACIAL SURGERY CAROLINAS MEDICAL CENTERPrivileges granted to Oral and Maxillofacial Surgeons (oral surgeons) shall be based upon theirtraining, experience, demonstrated competence, judgment and current capability. The scopeand extent of surgical procedures that each oral surgeon may perform shall be specificallydelineated. Effective May 19, 1998, oral surgeons currently practicing at Carolinas MedicalCenter, for 12 months or more, and having demonstrated their qualification and proficiency in theprocedures currently granted to them, by having performed several of each of these proceduresat the hospital, may continue to perform these procedures which they have previously beenapproved to perform.Oral surgeons who admit patients without medical problems may perform a complete admissionhistory and physical examination and assess the medical risks of the procedure on the patient ifthey are qualified to do so. Criteria to be used in identifying such qualified oral surgeons shallinclude, but shall not necessarily be limited to, successful completion of training requirements forcertification by the American Board of Oral and Maxillofacial Surgery.Patients with medical problems, in addition to their oral surgery problem(s), admitted to thehospital by qualified oral surgeons shall receive the same basic medical appraisal as patientsadmitted for other services. This includes having a physician who is a member of the medicalstaff perform an admission history, a physical examination, and an evaluation of the overallmedical risk; and record the findings in the medical record. The responsible oral surgeon shalltake into account the findings and recommendations of this physician in the overall assessmentof the specific oral surgery procedure proposed and the effect of that procedure on the patient.When significant medical abnormality is present, the physician shall decide if the scheduled oralsurgery may proceed in light of the medical problem(s). The oral surgeon is responsible for thatpart of the history and physical examination related to oral surgery. A physician member of themedical staff shall be responsible for the care of any medical problem(s) that may be present onadmission or that may arise during hospitalization of oral surgery patients.APPROVED BY THE MEDICAL EXECUTIVE COMMITTEE - MAY 19, 1998, MAY 16, 2000APPROVED BY THE BOARD OF COMMISSIONERS - JUNE 9, 1998, JUNE 20, 2000
  2. 2. CAROLINAS MEDICAL CENTER DEPARTMENT OF DENTISTRY, SECTION OF ORAL AND MAXILLOFACIAL SURGERY DELINEATION OF SPECIAL PRIVILEGES EMERGENCY ROOM AND TRAUMA SERVICEI do herewith request privileges to serve on the Emergency Room Call Schedule for Oral and Maxillofacial Surgery and as Oral and Maxillofacial Surgery (OMS)Consultant on the Trauma Service. To serve as OMS Surgery Consultant to the Trauma Service, I understand that I will be required to:1. Attend relevant monthly Multidisciplinary Trauma conferences, and2. Attend Trauma/Surgical Morbidity-Mortality Conference to be held in conjunction with quarterly departmental meetings, in which a patient under my care is presented, and3. Show evidence of continuing education in trauma surgery to include five (5) CME credits every two (2) years in trauma and reconstruction related topics, and4. Present evidence of certification by the American Board of Oral and Maxillofacial Surgery, or5. Show evidence that you are currently an "applicant" or "candidate" for certification b y the American Board of Oral and Maxillofacial Surgery.An individual who has not been certified by the American Board of Oral and Maxillofacial Surgery within five (5) years after successful completion of an approvedOMS residency is no long acceptable as an OMS Consultant on the Trauma Service.If Trauma Service privileges are granted, I agree, by affixing my signature to this delineation of privilege form, to provide continuous care and supervision ofpatients assigned to me while I am serving as Surgery Consultant on the Trauma Service.PRIVILEGES REQUESTED BY:_________________________________________________________________________ _____________________Signature Date_________________________________________________________________________Please type or print namePRIVILEGES RECOMMENDED BY:_________________________________________________________________________ _____________________Chief, Department of Dentistry Date_________________________________________________________________________ _____________________Section Chief, Section of Oral and Maxillofacial Surgery DateApproved by the Medical Executive Committee - May 19, 1998, MAY 16, 2000Approved by the Board of Commissioners - June 9, 1998, JUNE 20, 2000
  3. 3. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 3 CAROLINAS MEDICAL CENTER DEPARTMENT OF DENTISTRY, SECTION OF ORAL AND MAXILLOFACIAL SURGERY REQUEST FOR LASER PRIVILEGESOral Surgeons who wish to apply for Surgical Laser privileges must be credentialed in the procedure for which they wish to use the Surgical Laser.Please list type of Surgical Laser(s) to be used:__________________________________________________________________________________________________________________________________________________________________________________________________________________________Please present evidence of training in:1. Physics and Safety2. Application of the requested laser in Oral and Maxillofacial Surgery (i.e. course work with lab usage of each laser requested).SOURCE OF TRAINING:I. RESIDENCY: Please include the location, dates, type of residency and the name and address of the practitioner responsible for your training, orII. POST GRADUATE PROGRAM: * Please include course description, copy of course certificate and name and address of the practitioner responsible for your training, andIII. CASE EXPERIENCE AT CAROLINAS MEDICAL CENTER AND OTHER HOSPITALS: Please provide a list of cases and the name and address of the proctor(s).* Courses attended to change or advance privileges must be courses that have been recognized for Category I American Medical Association Physicians Recognition Awardcredit and/or are sponsored by a medical organization whose board is a member of the American Board of Medical Specialties and/or approved by the Department ofDentistry of Carolinas Medical Center and/or the American Board of Oral and Maxillofacial Surgery.Requested by:_________________________________________________________________________ _____________________Signature Date_________________________________________________________________________Please type or print nameRecommended by:_________________________________________________________________________ _____________________Chief, Department of Dentistry Date_________________________________________________________________________ _____________________Section Chief of Oral and Maxillofacial Surgery DateApproved by the Medical Executive Committee - May 19, 1998, MAY 16, 2000Approved by the Board of Commissioners - June 9, 1998, JUNE 20, 2000
  4. 4. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 4 CAROLINAS MEDICAL CENTER DELINEATION OF PRIVILEGES DEPARTMENT OF DENTISTRY, SECTION OF ORAL AND MAXILLOFACIAL SURGERYOral Surgeons who have successfully completed training requirements for certification by the American Board of Oral and Maxillofacial Surgery may apply for thefollowing procedures at Carolinas Medical Center (CMC). I wish to apply for the following procedures at Carolinas Medical Center: I am Board Certified by the American Board of Oral and Maxillofacial Surgery I have successfully completed training requirements for certification by the American Board of Oral and Maxillofacial Surgery CMC PROCEDURE HISTORY AND PHYSICAL EXAM NUMBER ORL-A1 Oral and Maxillofacial Surgeons may perform the medical history and physical examination, in order to assess the medical, surgical, and anesthetic risks of the proposed operative and other procedures. Any treatment not directly related to the dental or oral and maxillofacial surgery must be provided by a physician, and each patients general medical condition is the responsibility of a qualified member of the medical staff. CMC PROCEDURE DENTOALVEOLAR AND PREPROSTHETIC SURGERY NUMBER ORL-B1 Alveolectomy ORL-B2 Alveoloplasty with or without Exodontia ORL-B3 Apricoectomy and Pulpectomy of teeth ORL-B4 Cutaneous Fistula - Closure and/or repair ORL-B5 Excision of Hyperplastic Tissue ORL-B6 Frenulectomy or operation for tongue-tie ORL-B7 Jaw - Repositioning of muscles attached to the jaw ORL-B8 Operations of Gingiva
  5. 5. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 5 CMC PROCEDURE DENTOALVEOLAR AND PREPROSTHETIC SURGERY-CONTINUED NUMBER ORL-B9 Oral and Nasal Antral Fistula closure ORL-B10 Teeth - Removal or exposure of impacted teeth ORL-B11 Teeth - Removal of erupted teeth - surgical or non-surgical ORL-B12 Tooth replantation, transplantation and repositioning ORL-B13 Removal of Maxillofacial Tori and Exostoses ORL-B14 Tuberosity reduction and/or plasty CMC PROCEDURE INFECTIONS - ORTHOGNATHIC/MAXILLOFACIAL NUMBER ORL-C1 Intraoral incision and drainage ORL-C2 Extraoral incision and drainage-deep space infections ORL-C3 Jaw - Treatment of Osteomyelitis of the jaw ORL-C4 Sequestrectomy CMC PROCEDURE IMPLANTS - DENTAL OR FACIAL IMPLANTS FDA OR ADA APPROVED NUMBER ORL-D1 Maxillary and/or Mandibular Endosseous ORL-D2 Maxillary and/or Mandibular Subperiosteal ORL-D3 * For Maxillofacial Prosthesis (Extra Oral Prosthesis) - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES:
  6. 6. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 6 CMC PROCEDURE ORTHOGNATHIC AND RECONSTRUCTIVE SURGERY NUMBER (Correction and/or Reconstruction of Dentofacial Deformities) ORL-E1 * Bone - Harvesting of Bone (other than Iliac Crest Bone) as appropriate for the reconstruction of cases in the maxillofacial environment (Please check each procedure requested, see attached criteria): ___ Rib ___ Bone from the outer table of the Calvarium ___ Iliac Crest Bone ___ Tibial Plateau *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-E2 Genioplasties (Advancement, Reduction, Augmentation) ORL-E3 Implants - Related to Correction or Reconstruction (Maxillofacial) ORL-E4 Mandibular Osteotomies - Total and/or Segmental ORL-E5 * Maxillary/Midface Osteotomies - Total/Partial (LeForte I, II* and III*) - *Please provide documentation of training for LeForte II and III: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-E6 Maxillary/Midface Segmental Osteotomies ORL-E7 Primary or Secondary Bone Graft of Alveolar Cleft ORL-E8 Submucous Resection of Inferior Turbinates in conjunction with Orthognatic Surgery
  7. 7. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 7 CMC PROCEDURE ORTHOGNATHIC AND RECONSTRUCTIVE SURGERY - CONTINUED NUMBER (Correction and/or Reconstruction of Dentofacial Deformities) ORL-E9 * Submental Lipectomy in conjunction with orthognathic surgery - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-E10 Septoplasty Associated with Orthognathic Surgery/or Facial Reconstruction ORL-E11 Reconstruction of Maxilla and mandible with Autogenous bone and soft tissue grafts CMC PROCEDURE TEMPOROMANDIBULAR JOINT SURGERY NUMBER ORL-F1 Arthroscopy, Diagnostic ORL-F2 Arthorscopy, Operative ORL-F3 Arthroplasty ORL-F4 Arthrotomy ORL-F5 Condylectomy ORL-F6 Coronoidectomy ORL-F7 Dislocation Reduction ORL-F8 Excision of tumors ORL-F9 Injections ORL-F10 Jaw - Freeing Adhesions of jaw, TMJ ORL-F11 Meniscectomy ORL-F12 Reconstruction with costal chondral graft or other autologous tissue ORL-F13 Total joint replacement or reconstruction ORL-F14 Treatment of Dysfunctions
  8. 8. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 8 CMC PROCEDURE NASAL/SINUS: NUMBER ORL-G1 Caldwell-Luc and Nasal Antrostomy Procedures related to Orthognathic Surgery CMC PROCEDURE TRAUMA NUMBER ORL-H1 Alveolar Fractures - Open and closed reduction, including fixation ORL-H2 Arch bar & prosthetic Device Application ORL-H3 Bone plate/wire Osteosynthesis ORL-H4 Closure and Repair of Fistula ORL-H5 Fracture of Midface (LeForte I, II*, III*) open and closed reduction - *Please provide documentation of training for LeForte II and III: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-H6 Fracture of Mandible - Open and closed reduction, including fixation ORL-H7 Insertion Extraoral Pin Fixation ORL-H8 Jaw - Reduction Dislocation Jaw, TMJ ORL-H9 Lacerations (Please check each procedure requested): ___Ear ___Facial and Neck ___Intraoral ___Scalp Scar Division ORL-H10 Maxilla - Closed reduction ORL-H11 Maxilla - Open reduction, including fixation ORL-H12 Nasal Fractures - Open and closed reduction
  9. 9. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 9 CMC PROCEDURE TRAUMA - CONTINUED NUMBER ORL-H13* Nasal Orbital Ethmoid Complex (open and closed reduction) - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-H14* Orbital Blowout Fractures - Open and closed reduction - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-H15* Orbital Rim Fractures - Open and closed reduction - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-H16 Retrieval of Foreign Body ORL-H17 Scar Revisions including (Dermabrasion) ORL-H18 Zygomata Maxillary Complex Fractures -Open and closed reduction, including fixation ORL-H19 Zygomatic Arch Fractures - Open and closed reduction CMC PROCEDURE TUMORS RELATED TO ORAL AND MAXILLOFACIAL SURGERY NUMBER ORL-J1 Cysts - Excision of Odontogenic and Non-Odontogenic Cysts and Tumors of the hard and soft oral tissues ORL-J2 Biopsy - as relates to Oral and Maxillofacial Surgery (Please check each procedure requested): ___ Biopsy mouth and throat ___ Biopsy skin and subcutaneous ___ Biopsy bone, including marrow
  10. 10. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 10 CMC PROCEDURE TUMORS RELATED TO ORAL AND MAXILLOFACIAL SURGERY-CONTINUED NUMBER ORL-J3 Glossectomy, Partial (Non-malignant) ORL-J4 Jaw - Division of Jawbone (Mandible/Maxilla) ORL-J5 Jaw - Excision Joint Structure of Jaw ORL-J6 Jaw - Excision Jawbone ORL-J7 Jaw - Excision Lesion Jaw ORL-J8 Jaw - Incision of Jaw ORL-J9 Lip Lesions - Excision of non-malignant Lip Lesions with Repair ORL-J10 Mandibulectomy - Partial or Total (Non-malignant) ORL-J11 Maxillectomy, Partial (Non-malignant) ORL-J12 Sialolithotomy ORL-J13 Sialodochoplasty ORL-J14 Styloid Process and Ligament Surgery ORL-J15 Sublingual Gland, Excision of ORL-J16 Submandibular Gland, Excision of suspected benign process ORL-J17 Oral Tissue Defects - Reconstruction of Hard and Soft Oral Tissue Defects CMC PROCEDURE MISCELLANEOUS NUMBER ORL-K1* Laryngoscopy - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-K2 Microsurgical Procedures Related to Oral and Maxillofacial Structures ORL-K3 Tracheostomy - in relation to Oral and Maxillofacial procedures
  11. 11. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 11 CMC PROCEDURE ORTHOGNATHIC AND RECONSTRUCTIVE SURGERY - CONTINUED NUMBER (Correction and/or Reconstruction of Dentofacial Deformities) THE FOLLOWING PROCEDURES MUST BE APPROVED BY THE CHIEF OF THE DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, THE DEPARTMENT OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY AND THE DEPARTMENT OF PLASTIC SURGERY. ORL-E12* Primary or Secondary Closure of Cleft Palate and/or Alveolus - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-E13* Primary or Secondary Repair of Cleft Palate - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES: ORL-E14* Primary and/or secondary Repair of Cleft Lip - *Please provide documentation of training: NUMBER: YEAR: LOCATION: OUTCOMES:
  12. 12. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 12PRIVILEGES REQUESTED BY:_________________________________________________________________________ _____________________Signature Date_________________________________________________________________________Please type or print namePRIVILEGES RECOMMENDED BY:_________________________________________________________________________ _____________________Chief, Department of Dentistry Date_________________________________________________________________________ _____________________Section Chief, Section of Oral and Maxillofacial Surgery DateAPPROVED: MEDICAL EXECUTIVE COMMITTEE - MAY 19, 1998, MAY 16, 2000APPROVED: BOARD OF COMMISSIONERS - JUNE 9, 1998, June 20, 2000
  13. 13. Delineation of PrivilegesOral and Maxillofacial SurgeryPage 13 ORL-E1PRIVILEGE NAME: Harvesting of Bone (other than Illiac Crest Bone) as appropriate for the reconstruction of cases in the maxillofacial environment.DEFINITION OF PRIVILEGED PROCEDURE: Harvesting of bone (other than Illiac Crest Bone) as appropriate for the reconstruction of cases in the maxillofacialenvironment, including bone from the outer table of the Calvarium, Rib, etc.SPECIFIC SKILLS AND TRAINING REQUIRED: The harvesting of bone (other than Illiac Crest Bone) may be requested by Oral Surgeons who can presentacceptable documentation of appropriate training and competency to perform the procedure, including knowledge of the indications for the procedure and the risksinvolved.CREDENTIALS REQUIRED:1. Completed Oral and Maxillofacial Surgery Residency approved by the American Dental Association in which the harvesting of Non-Illiac Crest Bone is a part of the program. OR2. Completed Oral and Maxillofacial Surgery Residency approved by the American Dental Association ANDBe proctored for at least five procedures for the specific bone harvested (Rib, outer table of the Calvarium, etc.) and receive the favorable recommendation of theproctor and the Department of Dentistry, Section Chief of Oral and Maxillofacial Surgery.When Oral Surgeons have been approved to harvest bone (other than Illiac Cres Bone), they must make arrangements for appropriate surgical back-up by aNeurosurgeon, General Surgeon or Thoracic and Cardiovascular Surgeon prior to the start of the procedure.Sponsor: Stephen B. Hemmig, D.D.S.Revised: December 18, 1991Approved: 03/10/92Reviewed and Approved: 11/11/97APPROVED BY THE MEDICAL EXECUTIVE COMMITTEE - MAY 19, 1998, MAY 16, 2000APPROVED BY THE BOARD OF COMMISSIONERS - JUNE 9, 1998, JUNE 20, 2000

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