NOTE: At the time of a life-threatening clinical emergency, any practitioner may render whatever

Care he/she believes to be indicated regardless of the extent of his/her granted privileges.

Physician’s Name: Dr. Physician’s ID:

Physician’s Rank: Locum Assistant Consultant

Department: SURGERY

Section: THORACIC SURGERY

Date:

1
KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTRE
APPLICATION FOR CLINICAL PRIVILEGES

Physician’s Name DR. MD ROKNUGGAMAN Physicians ID:

(Please use block capital letter)

Specialty: THORACIC SURGERY , DEPARTMENT OF SURGERY

Date:

Place and “X” in the appropriate column

(Do not mark and “X” in more than one column for each procedure requested)

Sole Only with Assist

Section 1 Management Consultation Only
Admit patients X
Diagnostic thoracoscopy X
Inhaled foreign bodies X
Intercostal nerve block X
Lung biopsy X
Management of pneumothorax (needle, chest tube insertion,
X
drainage system
Mediastinoscopy X
Mediastonotomy X
Pericardial window X
Pleural effusion X
Rib resection X
Rigid bronchoscopy X
Thoracentesis X
Thoracic sympathectomy X
Thoracic trauma X
Tracheostomy X
Tube thoracotomy X

2
KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTRE
APPLICATION FOR CLINICAL PRIVILEGES

Physician’s Name DR. MD ROKNUGGAMAN Physicians ID:

(Please use block capital letter)

Specialty: THORACIC SURGERY , DEPARTMENT OF SURGERY

Date:

Place and “X” in the appropriate column

(Do not mark and “X” in more than one column for each procedure requested)

Sole Only with Assist

Section 2 Management Consultation Only
Bronchopleural fistula X
Carinal resection X
Chest wall deformity X
Chest wall tumors X
Decortications X
Diaphragmatic operations X
Esophageal resection with replacement X
Hiatus hernia repair X
Intrapulmonary abscess X
Lobectomy X
Mediastinal tumor X
Pneumolysis and thoracotomy X
Pneumonectomy X
Pulmonary metastatectomy X
Pulmonary resection for infections X
Segmentectomy X
Sleeve resections X
Subglottic resection X
Surgery for bullous disease X
Surgery for esophageal motility disorders X
Surgery for hydatid disease X
Surgery for reflux X
Thoracic outlet syndromes X
Thoracoplasty X
Thoracoscopic surgery X
Thymectomy X
Tracheal resection X
Tracheoesophageal fistula X
Zenker diverticulum X

3
KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTRE
APPLICATION FOR CLINICAL PRIVILEGES

Physician’s Name DR. MD ROKNUGGAMAN Physicians ID:

(Please use block capital letter)

Specialty: THORACIC SURGERY , DEPARTMENT OF SURGERY

Date:

Place and “X” in the appropriate column

(Do not mark and “X” in more than one column for each procedure requested)

Sole Only with Assist

Section 3 Management Consultation Only
Bronchoscopy X
Bronchial laser treatment X
Conscious sedation X
Excision of diaphragm / re-construction X
Diaphragmatic pacing X
Esophageal Stenting X
Extracorporeal membrane oxygenation (ECMO) Cannulation X
Flexible bronchoscopy X
Flexible Esophagus X
Laser bronchoscopy X
Lung transplantation X
Pericardiectomy for mesothelioma X
Pleuro-pneumonectomy X
Tracheobronchial stenting X
Volume reduction surgery X

4
KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTRE
APPLICATION FOR CLINICAL PRIVILEGES

Physician’s Name DR. MD ROKNUGGAMAN Physicians ID:

(Please use block capital letter)

Specialty: THORACIC SURGERY , DEPARTMENT OF SURGERY

Date:

Place and “X” in the appropriate column

(Do not mark and “X” in more than one column for each procedure requested)
Please attach to this form evidence of level of training & expertise attained to carry our requested procedures

ADDITIONAL CLINICAL PRIVILEGES

(Special Procedures)
(type detailed description)
Use separate sheet of paper of required & attach to this sheet

IF AT ANY STAGE YOU WISH TO PERFORM ANY SURGICAL OR THERAPEUTIC PROCEDURE WHICH IS NOT LISTED
IN THIS APPLICATION, YOU MUST REFER IT TO THE CREDENTIALS & APPOINTMENT COMMITTEE

SIGNATURES

Signature: Date: 24/03/2021

MD Roknuggaman, MBBS, MSc
Locum Assistant Consultant, Thoracic Surgery
Department of Surgery
Recommended: Date:
Norberto Santana Rodriguez, MD
Section Head, Thoracic Surgery
Department of Surgery

Recommended: Date:
Alaa Abduljabbar, MD
Acting Chairman
Department of Surgery

Recommended: Date:
Hassan Al Rayes, MD
Chairman
Medical Staff & Scientist Credentials and
Clinical/Professional Privileges Committee

Approved: Date:
Abdulaziz Alrajhi, MD

5
KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTRE
APPLICATION FOR CLINICAL
Chief PRIVILEGES
Medical Officer, Medical Affairs-Riyadh

Physician’s Name DR. MD ROKNUGGAMAN Physicians ID:

(Please use block capital letter)

Specialty: THORACIC SURGERY , DEPARTMENT OF SURGERY

Date:

Place and “X” in the appropriate column

(Do not mark and “X” in more than one column for each procedure requested)