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35 AHP Clinical Privileges Update Form John Skinner, PA Department of TCV Surgery 1 have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Pra As the Supervising Physician/Ql Liaison/Department Chair/Medical Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to-requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last -~ppointment, we have reviewed applicable information from the following sources of quality and utilization data: [M'").4edical Record Review GV S,;.ontinuingEducation Conferences ~~sical & Mental Health related to Job Performance [ 'Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA _ We find as follows: ri~ceptable review with recommendation of reappointment with clinical privileges as requ~sted. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges as requested, but subject to a!.:-. -j' -'f-;- months. I/'J~(O - j IDat l -1" ~e;dl 'n~"j NJ) Gorav Ailawadi, M.D. Kenneth Cherry, M.D. David Jones. M.D. \ ~1.i1\'P Clinical Care Svcs Ad inistrator (for MCemployees) Chai,/RPC Medicalti;;'cto, Signature (fo, "SF employees) Irving Kron, M.D. revised 3/1/2005

36 ~ '. "-=- :..".;, AHP Clinical Privileges Update Form 4h Y)~ n~ Department Of_---=-I--=CJ)=--_~_~~~----- aave reviewed the privileges previously grauted (copy attached) to me and reque New Privileges to be Added (please indicate category level and type of experience): wing changes: Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. As the Supervising Physician/Ql Liaison/Department Chair/Medical Director/ Service Center Administrator, we have reviewed the above-named AHJP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last ~"'pointment, we have reviewed applicable information from the following sources of quality and utilization data: [i'"..,medical Record Review [l?' Continuing Education Conferences 0 ~Physical & Mental Health related to Job Performance 0 ~ Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (f, hours continuing education documentation required every 2 years) Oili~. Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA We find as follows: ~AccePtable review with recommendation of reappointment with clinical privileges as requested. tion plan in place with recommendation of reappointment with privileges months. Benjamin Peeler, M.D. Gorav Ailawadi, M.D. Kenneth Cherry, M.D. Nancy Harthun, M.D. David Jones, M.D. 1\ Irving Kron, M.D. Da dical Director Signature (for HSF employees) revised 3/1/2005

37 , AHP Clinical Privileges Update Form,=--~_J..:...::c)~h----,--=--t\~S.=.r...=(4~n--,- :J_-.J--- Department Of_JO/--L.:.~_~~~~~ _ ~.,.. have reviewed the privileges previously granted (copy attached) to me and request.~ew Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Prac I As the Supervising Physician/QI Liaison/Department Chair/Medical Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: /-... [3'" Medical Record Review Gf Continuing Education Conferences ~ Physical & Mental Health related to Job Performance c:t' Risk Management Events/Quality Management Reports for claims B' Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other We rfind as follows: Acceptable review with recommendation of reappointment with clinical privileges as requested. o ith recommendation of reappointment with privileges Benjamin Peeler, MD Kenneth Cherry, MD Thomas Daniel. MD Nancy Harthun, MD -7(zA.lLoy Chair/RPC Medical Director Signature (for HSF employees) Printed Name Trv; Dg KroD " MD revised 3/1/2005

38 David Jones, MD John Kern. MD Alternat Supe ising Physician Signature Robert Shen, MD Benj amin Ko./zoW, MD Alternate Supervising Physician Signature revised 3/1/2005

39 AHP Clinical Privileges Update Form _~--'--l.o",-h,-"--yl_s~,,,--,{6:;:...n_h.l:j_-'- Departmentof_----'--""""""~..,g...<Jo~~A====:-- _ ~ have reviewed the privileges previously granted (copy attached) to me and request t Jew Privileges to be Added (please indicate category level and type of experience): ing changes: Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Pructi. Pll-c As the Supervising PhysicianlQI LiaisonlDepartment ChairlMedical Director! Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~~ ~ ~ JR( Medical Record Review JX ~ Continuing Education Conferences 0 Dil.Physical & Mental Health related to Job Performance ~ o Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA _ We find as follows: ~cceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective on plan in place with recommendation of reappointment with privileges as requested, but subject t months. ~ Ben Peeler, MD Ken Cherry, MD Thomas Daniel, MD Nancy Harthun,MD f"1 ~ llcxr Clinical Care Svcs Ad t:.0r (for Me employees) Chair/RPC Medica Director Signature (for HSFemployees) Irving Kron,MO- revised 3/1/2005

40 1{ rtlo1 ~lul{' Alternate Su ervising Physician Signature Printed Printed David Jones, MD Name John Kern, MD Name ~6~ Alternate S~ignature Alternate Sup rvlsing Physician Signature ;/ / K. Robert Shen, MD Curtis Tribble, MD Harrv Wellons. MD revised 3/812005

41 AHP Clinical Privileges Update Form.,5J_'~-,-"",Q~h~' -,-h->-sl<.="o,-",~=h...!..:-~-===-t Department of_--'!.--=..::...:==--=-~::...=.,~ _ I~ve reviewed the privileges previously granted (copy attached) to me an e t the following changes:, Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding, If riviieges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Pr ctlti ner Databa As the Supervising Physician/QI LiaisonlDepartment ChairlMedical Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: [{'.Medical Record Review ~ Continuing Education Conferences. Physical & Mental Health related to Job Performance ct' Risk Management Events/Quality Management Reports' for claims Ef Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other _ We find as follows: o Acceptable review with recommendation of reappointment with clinical privileges as requested. o co~c rns noted on review with corrective ction plan in place with recommendation of reappointment with privileges as r ueste ~but subje~ a review i. months. /; 1 O~ Ben Peeler, MD. Dte y Supe??I~ - Ken Cherry, MD ~,.r1a;e~u -~ Thomas Daniel MD Nancy J-tarth\ln MD Service Cntr A ministrator (for Medical Centeremployees) Chair/Medical Director Signature (for HSF employees) Iryjng, Kron, MD revised1/8/2003

42 AHP Clinical Privileges Update Form (Continued) -'''John Skinner, PA-C Signatures: ~ a ~ ~ {) 2,ct D te tr~41of ~7;~t/ David Jones, MD John A. Kern, MD Curt Tribble, Harry Wellons, MD MD revised 5/27/2003

43 r Additional Privileges ) ) A The applicant will not underake patient management except in Emergency B The applicant will manage patients with a phsyician present C The applicant will manage patients in collaboration and/or consultation with the phsyician Peds Adol Adult Geriatric Authorization to prescribe C C Order EMG r (' ECG Administration C. C (., Intubate C Reopen Explore chest (\ (- Bronchoscopy r, C. Mini Tracheostomy (! e Place trans-venous pacer (' c." ff\ -0 John Skinner, MD Printed Name Ben Peeler, MD Printed Name Ken Cherry, Printed Name MD Thomas Daniel, MD Printed Name Nancy Harthun, Printed Name MD David Jones, Printed Name MD Alternate ~ervisj>'- PhYSiCe:w~ ~.-/('J, John Printed Kern, MD Name Curtis Tribble, MD Alternate Jnl'd'9rvising Physician Sigl'l1lt Chair/Medical Director Signature

44 HCP Clinical Privileges Update Form John Skinner,PA Departmentof ~T~C~"~S~u~r~g~e~rv~ _ I have reviewed the privileges previously granted (copy attached) to me and request the following changes: '4ew Privileges to be Added (please indicate category level and tyi!e of experience): _umbar Puncture SwanGanz Catheter Placement Venous Cutdown IASP placement & Mgmt Evaluate EEG Intub~a-t-e~ Reopen and Explore Chest Bronchoscopy Mini tracheostomies Place trans-venous pacer Current Privileges not to be renewed: *,':oi. "Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and recei -e a copy 0 e report to be filed with the National Practition aban. /- As the Supervising Physician!QI LiaisonlDepartment Chair/lVIedical Director! Service Center Administrator, we have reviewed the above-named HCP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named HCP's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality /'"""-ndutilization data: Medical Record Review Hep's Health and Mental Status Continuing Education Conferences Sentinel EventslRisk Management Reports o o We find as follows: -,::. Acceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges as requested, but subject to a review in months. 1(0'~ ~,~~~&b~e~~~t~er~i~ ~~m~4~~~i'~tr~a~to~'r~t4~4~a_<~' b~)101 Revised 3/21102

45 / Nanc Harthun MD / ' Collaborating Physician Signa ure David Jones MD Collaborating Physician Signature \ John Kern MD Collaborating Physician Signa Curtis Tibbie, MD Collaborating Physician Signature Harr Wellons MD Collaborating Physician Signa ure Collaborating Physician Signature Collaborating Physician Sign Irvin Kron MD Chair/Medical Director Signature Revised 3121/02

46 AHP Clinical Privileges Update Form ~J~o~h~n~S~ID~ n~n~er~ Departmentof _=T~h~o~r~a~c~ic~&~T~C~a~r~d~io~,~'a~s~c~u~la~r _ I have reviewed the privileges previously granted (copy attached) to me and request the following changes: /New Privileges to be Added (please indicate category level and type of experience): Ll\'V'bo. ou IIIddlV'-l' < Ej/!2llJak EE6 I j Slll(lltl bciit17 <1&Nv plgu!m.lv>.f Iduhd-L \lralijl~ rfr\;c(,wv\ &v 1l:N'\. f ld()i(9y=f cb.(~+ +rcc~jas J.<TWlI (~ ftai1 S -II {.l1tnj, fr C-U-- =Privlleges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. As the Supervising Physician/QI Liaison/Department Chair/Medical Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last appointme,nt, we have reviewed applicable information from the following sources of quality and utilization data: "'~ LJ Medical Record Review Continuing Education Conferences o Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Physical & Mental Health related to Job Performance o Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other _ We find as follows: ~table review with recommendation of reappointment with clinical privileges as requested. Ben Peeler, MD (/z ' 7,(07 I 1-1'bu/U) I I ' Alternate Ivan Crosby, MD Thomas Daniel, MD Nancy Harthun, MD David Jones, MD

47 .,atj I John Kern. MD Curtis Tribble, MD Harry Wellons. MD Alternate Supervising Physician Signature Alternate Supervising Physician Signature nistator (for Medical Center employees) Irving Kron, MD revised 1/8/2003

48 ., Privilege List for: Physician's Assistant 26-Scp-02 Nnme: r is-r-»: PLRASE MARK AS REQOESTll:D ONL'f THOSE AlU!W'l wmtr.e YOU A.RE lmgdlarl Y i\ssigned TO PRACTICE; 1tl\mR.GENCY PIUYILEGRS SHOULD DE ~o WImRE vou AltE TlIE DESIGNATED PERSON TO COVER.AN AREA IN WBICH YOU no NOT REGm...uu.y PRACflCE. AREAS IN WHICH YO(l DO NOT REGtlLARLY PRACTICE SHDDLD BE LltFI' DLANK...I,.CCORDING TO CATEGORY, ENTER A. B. OR C IN THE COLUMN NEXT 1'0 THE I.lSTED PlUVILEGE: A 1be upplicllnt will nor undct'tlll.:e pllticnc lllluui\toment except in emergency. l3 The I!ppLi~f will manage pntienls wictj phy'icilul present, C The II11PliC::lIl( wiu mllllli/:t: plltie.nu; in colln.h~ign lij)djor consultation wirb. the physit:illn. D The: applicunt will manage PllueIIlts ASan indep~dc:nt clinicil1ll fum::tion. General Genern1 General Geullral General General General General General General Gencl'lIl ~aneral.-rocl!uure Procedure Procedure Procedure Procedure Procedure Procedure l'roceduro Procedure Procedure Procedure. Procedure General General Procedure Procedure Procedure Procedure Procedur-e Procedure Procedure Procedure Procedure Procedure Procedure H~'~dure 1,dore Procedure Order-ECG Order - Labs Order EEG Order Rlldi0eTUPhli Order Holter MoDitoring Order - EchoClrdiogram Order Medications. Order Consults Hospital Rounds Patient Education History and Physical Authorl:zed to Preseribe Chest Tub~ Insertion & Mgt An estll~l a Local Lumbar Puncture Wound Met Removal of Sutures/Staple:! Thoracentests Wound Mgt - Debridement Arterial Une placement Cath Swan Gnnz catheter' placement Insertion, Catheter - Bladder Feeding tube Placement Venous cutdown Ve'l1ipuncture Order- Diet Ordcr-EMG IAllP - Placement &: Munaj!ement NG Tube Insertion Catheter - IV Per-ipheral - PhlcCIMnt & Mgt ECG A.dmlnistnlHotl Halo Vest - Adjustment Ernlo VI:Bt - Pin Care HWoVest - Placement Injections > Intrademllll Injections. Inti-nmuBcular Intradermal Skin Testjoc IV Medications & Fluids Administr'lltion Suturing -MAjor Suturinr: - Minor Surgery A1lsiBt -!at & 2nd A&sistin~ Neonlltal Peri Adol A.dul~ Geriatric:. C L (... (' ( c. ( c c, L. c. c, c, C c. C C L L r. L r C. c, ( c c- ('. c L r. c- c... c:.. L (. c.. c. (.., c z, c- c. (... c. c:. c- c, c, c: c.: G- c.- L.. c:- L C L..- C c: '- c. c.. c- c c- L L- e:-. (-. c- c, c,...-- L c...- l- L, L {.' L- c..- I. c- C/ t-- t:.- Page 1 OT 2

49 -. Procedure Sur-llery Assist- HIln'e&t:ing Vein Procedure Surgery Assist Posltlnn & Prep Procedure Injectlona- Intrnvenuus General Evaluate- ECG G!!nerlll Evaluate- Echceardlcgram General Evaluate BEG General Evaluate» Holter Monitorin(! General Evaluatc. Labs Gellcr-lil Evaluate- Rlldioerllprn. OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric ~ v'c... ~ \/c.. VL -./'c.. /c... V'c. V<c/c, v-c... v'l v[ t/c /e- /c. DATE tl.. Naltle.>rl1'\lcd P'"l'" As the Collaborating Physician and Department Cbair/Scnice Center Administrator, we have reviewed the abovenamed practitioner's level of experience, past performance and quality Indicators (if renewing privileges) as related '0 requested privll egcs and 'W" that tb e above named qualiflcatlons are approprlate, DATE /D/>' /~J., qg~f. 'IS""'~~ SI'~'''R /J.""lJK.!f!t~, '1- (j" (J, (I ~- c.g-t~b\'\e DATE 1\I>t'(J>ttP~fvlslnl: I'hyslci lime Prln(l!d 4., _---L-lb I f uj_csl DAT =j-l+-. (_0 {(if r~~ DATE ~ Ie tc ~ln~physlclui1!':lgnn~lin: Nllmc Prtnted. ~ - ;: De Chair or Svc CClIlc:r Admlnl.tnltor /l\lime p~ ~~/"t)--+,iii.f DATE ( I I f)l.- DATE DATE Altem21lc SUpBlV;s;lngPhYIOlclan Signature Name Prlnled DATE AllernatB Suparvl61ng Phy&lc:lan SlanBtufll Name Prlnttld Page 2 of 2

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