|
|
- Gyles Bradford
- 5 years ago
- Views:
Transcription
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
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
50
X X AHP Clinical Privileges Update Form Joseph Fallon, PA Department of Radiology -------I have reviewed the privileges previously granted (COP)' attached) to me and request the following
More informationAHPClinical Privileges Update Form _Carol Ballew Department of Cardiology Clinic have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges
More informationDEPARTMENT OF NEUROSURGERY PHYSICIAN ASSISTANT ADVANCED PRIVILEGES
To be eligible to apply for privileges as a Physician Assistant in Neurosurgery, the applicant must currently possess Physician Assistant Core Privileges as a member of the Kaleida Health Medical/Dental
More informationAHP Clinical Privileges Update Form Patrice Neese Department of Surgery I have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added
More informationAHPClinical Privileges Update Form Carolyn Brady Department of Heart Center/Cardiology Clinic I have reviewed the privileges previously granted (copy attached) to me and request the following changes:
More informationAPP PRIVILEGES IN SURGERY
APP PRIVILEGES IN SURGERY Education/Training Licensure (Initial and Reappointment) Required Qualifications Successful completion of a PA or NP program Current licensure as a PA or RN in the state of California
More informationHuntington Memorial Hospital. Delineation Of Privileges Physician Assistant Privilege Form
JOB SUMMARY: A physician assistant (PA) may only provide those medical services which he or she is competent to perform and which are consistent with the physician assistant's education, training, and
More informationPenrose-St Francis Hospital
Advanced Practice Nurse Please check applicable credential [ ] Nurse Practitioner [ ] Clinical Nurse Specialist [ ] Certified Nurse Midwife [ ] Certified Registered Nurse Anesthesist Area of focus _ ***************************************************************
More informationCARDIOVASCULAR SURGERY PHYSICIAN ASSISTANT CLINICAL PRIVILEGES
Notice to Applicant: Applicants have the burden of producing information deemed adequate by University of Mississippi Medical Center (UMMC) for a proper evaluation of current competence, current clinical
More informationAPP PRIVILEGES IN MEDICINE
APP PRIVILEGES IN MEDICINE Education/Training Licensure (Initial and Reappointment) Required Qualifications Successful completion of a PA, NP or CNS program Current Licensure as a PA, RN or CNS in the
More informationDelineation of Privileges and Credentialing for Critical Care Procedures
Delineation of Privileges and Credentialing for Critical Care Procedures Marialice Gulledge, DNP, ANP-BC Chief, Nurse Practitioner Trauma and Acute Care Surgery Disclosure Faculty/presenters/authors/content
More informationClinical Privileges Update Form
Clinical Privileges Update Form Mark Mendelsohn epartment of Pediatrics I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,
More informationUNM SRMC NURSE PRACTITIONER (NP) & LICENSED INDEPENDENT PRACTITIONER (LIP) CLINICAL PRIVILEGES. Name: Effective Dates:
o o o Initial privileges (initial appointment) Renewal of privileges (reappointment) Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved
More informationPrivileges for San Francisco General Hospital # 10
PEDIATRICS 2014 FOR ALL PRIVILEGES: All complication rates, including transfusions, deaths, unusual occurrence reports, patient complaints, and sentinel events, as well as Department quality indicators,
More informationGeneral Internal Medicine Clinical Privileges REAPPOINTMENT Effective from July 1, 2015 to June 30, 2016
Name: Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants must meet the following requirements as approved by the governing body, effective: 04/Jun/2013. Applicant:
More informationq' Clinical Privileges Update Form U~lVERSTY '!VRGNA Bhiken Naik Department of Anesthesiology HEALTH SYsTEM have reviewed the privileges previously granted to me and request the following changes to include
More informationClinical Privileges Update Form Kenneth Liu Department of. Radiology I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,
More informationSCOPE OF PRACTICE. Internal Medicine Residency USF Health Morsani College of Medicine University of South Florida
SCOPE OF PRACTICE Internal Medicine Residency USF Health Morsani College of Medicine University of South Florida Background Internal Medicine Residency is clinical training in a supervised environment
More informationAbout the Critical Care Center
Patient and Family Education Section 2 About the Critical Care Center The 5-Southeast and 5-East units 5-Southeast and 5-East When You Arrive for a Visit Patient Services Specialist Waiting Rooms Patient
More information~ ~..._..._...~..._ CLINICIAN SIGNATURE
Clinical Privileges Update Form UNlVEHSrry qrvirginiau Barbara Wilson Department of Dermatology L--. HEALTH SYsTEM ~ ~ I have reviewed the privileges previously granted to me and request the following
More informationRegions Hospital Delineation of Privileges Nurse Practitioner
Regions Hospital Delineation of Privileges Nurse Practitioner Applicant s Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and basic
More informationAPP PRIVILEGES IN OTOLARYNGOLOGY
APP PRIVILEGES IN OTOLARYNGOLOGY Education/Training Licensure (Initial and Reappointment Required Qualifications Successful completion of a PA or NP program Current Licensure as a PA or RN in the state
More informationUPMC For Reference Only PHYSICIAN ASSISTANT 2014
Summary of Services and Availability (by location) Each location has sufficient space, equipment, staffing and financial resources in place or available in sufficient time as required to support each requested
More informationCRITICAL CARE CLINICAL PRIVILEGES St. Dominic Jackson Memorial Hospital
PRINTED NAME: DATE: All new applicants must meet the following requirements as approved by the governing body, effective: 02/25/2016 INSTRUCTIONS Applicant: Check the requested box for each privilege requested.
More informationSkills/Experience Checklist Home Health Registered Nurse
This form is a self-assessment of your current skills and abilities. This form is also used to document skill demonstration. EMPLOYEE PROFILE Last Name First Name Middle Initial Employee Number Direct
More informationINSTRUCTIONS All new applicants must meet the following requirements as approved by the UNM SRMC Board of Directors effective: June 2017:
o Initial privileges (initial appointment) o Renewal of privileges (reappointment) o Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved
More informationPrivilege Request Form Emergency Medicine
Privilege Request Form SECTION I GENERAL REQUIREMENTS EMERGENCY MEDICINE Requested Staff Category Active Courtesy Consulting Affiliate Basic Education: MD or DO INITIAL APPOINTMENT Minimal formal training
More informationUNM SRMC NURSE ANESTHETIST (CRNA) CLINICAL PRIVILEGES
o Initial privileges (initial appointment) o Renewal of privileges (reappointment) o Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved
More informationNURSE PRACTITIONER (NP) CLINICAL PRIVILEGES ORTHOPEDIC SURGERY
Name: Page 1 Initial Appointment (initial privileges) Reappointment (renewal of privileges) All new applicants must meet the following requirements as approved by the governing body effective: / /. Applicant:
More informationPEDIATRIC PULMONOLOGY CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for
More informationSPECIALTY OF PULMONARY MEDICINE Delineation of Clinical Privileges
SPECIALTY OF PULMONARY MEDICINE Delineation of Clinical Privileges Criteria for granting privileges: Current board certification in Internal Medicine by the American Board of Internal Medicine or the American
More informationCritical Care Medicine Clinical Privileges
Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,
More informationADOLESCENT MEDICINE CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 06/03/15 Applicant: Check off the Requested box for each
More informationMed/Peds Trainee Milestones and Goals and Objectives for Promotion Protocol for when to Call Faculty Johns Hopkins Hospital
Med/Peds Trainee Milestones and Goals and Objectives for Promotion Protocol for when to Call Faculty Johns Hopkins Hospital PGY 1 Interns should have close supervision by a resident and/or attending and
More informationLoma Linda University Medical Center Loma Linda, CA MEDICINE SERVICE PRIVILEGE FORM. Specialty: Page 1 of 15
Specialty: Page 1 of 15 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5)
More informationPEDIATRIC EMERGENCY MEDICINE CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 1/6/2016 Applicant: Check off the Requested box for each
More informationUNMH Anesthesiology Clinical Privileges
For eligibility to request privileges in Anesthesiology, applicants must have appointment as a Faculty member of the UNM Department of Anesthesiology & Critical Care Medicine. All new applicants must meet
More informationSan Antonio Uniformed Services Health Education Consortium San Antonio, Texas
San Antonio Uniformed Services Health Education Consortium San Antonio, Texas Department of Medicine General Medicine Wards, Medical Intensive Care Unit (MICU) and Coronary Care Unit (CCU) Supervision
More informationNAME: DATE: MARGARETVILLE HOSPITAL PHYSICIAN ASSITANT/NURSE PRACTITIONER ED CLINICAL PRIVILEGES
SUPERVISING PHYSICIAN(s): MARGARETVILLE HOSPITAL PHYSICIAN ASSITANT/NURSE PRACTITIONER ED CLINICAL PRIVILEGES The following privileges are required to practice in the Emergency Room of Margaretville Hospital:
More informationUNM SRMC CRITICAL CARE PRIVILEGES
UNM SRMC INSTRUCTIONS All new applicants must meet the following requirements as approved by the UNM SRMC Board of Directors effective May 24, 2017 Applicant: Check off the "Requested" box for each privilege
More informationRegions Hospital Delineation of Privileges Physician Assistant Emergency Medicine
Regions Hospital Delineation of Privileges Physician Assistant Emergency Medicine Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting.
More informationGENETICS CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for
More informationPRACTICAL SKILLS. Objective examination of the patient
RACTICAL KILL tudent's data. These fields are completed by the student First and last name No of study book In the next tables, total of 76 practical skills are listed by topics that you should develop
More informationPRIVILEGE APPLICATION FORM - [Mercy Medical Center]
Current Privilege Status Key Practitioner's Current Privilege status is signified in ( ) preceding each privilege. G = W = Withdrawn T = Temporary P = With Proctor A = Assist with C = With Consult E =
More informationRegions Hospital Delineation of Privileges Critical Care
Regions Hospital Delineation of Privileges Critical Care Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and basic
More informationJob Ready Assessment Blueprint. Medical Assisting. Test Code: 3055 / Version: 02
Job Ready Assessment Blueprint Medical Assisting Test Code: 3055 / Version: 02 Measuring What Matters Specific Competencies and Skills Tested in this Assessment: General Office Procedures Greet and receive
More informationAPP PRIVILEGES IN NEUROSURGERY
APP PRIVILEGES IN NEUROSURGERY Education/Training Licensure (Initial and Reappointment) Required Successful completion of a PA, NP or CNS program Current Licensure as a PA, RN or CNS in the state of CA
More informationAPP PRIVILEGES IN UROLOGY
APP PRIVILEGES IN UROLOGY Education/Training Licensure Required Qualifications Successful completion of a PA or NP program Current Licensure as a PA or RN in the state of CA Current certification as a
More informationSupervision Residents will be supervised by attendings and upper-level residents who are competent to perform the specific procedure.
Family Medicine Residency Procedure Curriculum Elly Riley, DO Rotation Goal After completing the longitudinal and block procedural curriculum, the resident will be competent to independently perform core
More information2016 SUMMER STUDENT NURSE EXTERNSHIP PROGRAM SKILLS CHECK LIST
2016 SUMMER STUDENT NURSE EXTERNSHIP PROGRAM SKILLS CHECK LIST STUDENT NURSE EXTERNNAME SCHOOL OF NURSING STUDENT AGREEMENT: I request the Clinical Skills Check list be released to (hospital/agency). I
More informationPPE Policy: Appendix I Clinical PPE Selection Certification
PURPOSE The following list of procedures is meant to be the basis for a department/patient care units orientation concerning the use of personal protective equipment. However, it is not meant to be all
More information1. CRITICAL CARE. Preamble. Adult and Pediatric Critical Care
1. CRITICAL CARE Complete understanding of the following paragraphs is essential to appropriate billing of the critical care fees. Members of the team billing the Critical Care Payment Schedule can not
More informationDELINEATION OF PRIVILEGES - ANESTHESIOLOGY
KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES - ANESTHESIOLOGY PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications
More informationCLINICAL PRIVILEGES- PEDIATRIC ACUTE CARE NURSE PRACTITIONER
Name: Page 1 Initial Appointment Reappointment Department Specialty Area All new applicants must meet the following requirements as approved by the governing body effective: 09/16/15 Applicant: Check off
More informationDEVELOPMENTAL-BEHAVIORAL PEDIATRICS CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 04/03/2013. Applicant: Check off the Requested box for
More informationClinical Privileges Profile Family Medicine. Kettering Medical Center System
Clinical Privileges Profile Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested. Applicants have the burden
More informationHuntington Memorial Hospital Delineation Of Privileges Neonatology Privileges
NEONATOLOGY PRIVILEGES NEONATOLOGY CORE PRIVILEGES 1. Successful completion of an ACGME or AOA accredited residency in General Pediatrics. 2. Board certification or in the process of certification by the
More informationCLINICAL PRIVILEGES- WOMEN S HEALTH NURSE PRACTITIONER
Name: Page 1 Initial Appointment Department Reappointment Specialty All new applicants must meet the following requirements as approved by the governing body effective: March 4, 2015. Applicant: Check
More informationUNM SRMC Nephrology Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNM SRMC Board of Directors, effective August 213, 2017 Initial Privileges (initial appointment) Renewal of Privileges (reappointment)
More informationNEONATAL-PERINATAL MEDICINE CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for
More informationSTANDARDIZED PROCEDURE HEPATIC ARTERY INFUSION OF CHEMOTHERAPY (Adults, Peds)
I. Definition Hepatic arterial infusion (HAI) of chemotherapy is accomplished by a small drug delivery system or pump that is implanted in a subcutaneous pocket in the lower abdomen. The pump reservoir
More informationDeveloping an ED Facility Charge Calculator March 3, :00pm
Developing an ED Facility Charge Calculator March 3, 2016 4:00pm Neal Kothe, The Ohio State University Wexner Medical Center Carol Gray, The Ohio State University Wexner Medical Center Conflict of Interest
More informationPULMONARY MEDICINE CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for
More informationUNMH Critical Care Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective November 17, 2016: INSTRUCTIONS: Applicant: Check off the requested box for each privilege requested.
More informationCHAP2-CPTcodes _final doc Revision Date: 1/1/2017
CHAP2-CPTcodes00000-01999_final103116.doc Revision Date: 1/1/2017 CHAPTER II ANESTHESIA SERVICES CPT CODES 00000-09999 FOR NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES Current
More informationI: Neurological/ Neurosurgical
I: Neurological/ Neurosurgical College of Licensed Practical Nurses of Alberta, Competency Profile for LPNs, 3rd Ed. 81 Competency: I-1 Neurological Nursing I-1-1 I-1-2 I-1-3 I-1-4 Demonstrate knowledge
More informationDepartment of Critical Care Restricted Registration Proposal for Call Coverage by Residents in TOH Intensive Care Units
Department of Critical Care Restricted Registration Proposal for Call Coverage by Residents in TOH Intensive Care Units Background: In 2004, the CPSO adopted a model for a pilot project to institute limited
More informationNurse Practitioner dictionary was approved by PMSEC on September 14, 2017
Summary Page NURSE PRACTITIONER DICTIONARY APPROVAL Nurse Practitioner dictionary was approved by PMSEC on September 14, 2017 REVIEW PANEL COMPOSITION The panel was composed of two co-chairs with expertise
More informationPolicy for use of the Royal Marsden Manual of Clinical Nursing Procedures (9th Edition)
Policy for use of the Royal Marsden Manual of Clinical Nursing Procedures (9th Edition) Document Summary This Policy defines the clinical procedures for all Clinical staff (including temporary staff, contracted
More informationAPP PRIVILEGES IN RADIATION ONCOLOGY
APP PRIVILEGES IN RADIATION ONCOLOGY Education/Training Licensure (Initial and Reappointment) Required Qualifications Successful completion of a PA or NP program Current Licensure as a PA or RN in the
More informationORTHOPEDIC SURGEON OFFICE
ORTHOPEDIC SURGEON OFFICE A recent PA graduate is sought for an orthopedic surgeon office at a top teaching hospital in New York City immediately. This full time position is offered with benefits and health
More informationPEDIATRIC CARDIOLOGY CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 08/05/2015. Applicant: Check off the Requested box for
More informationPolicy on Resident Supervision. University of South Florida College of Medicine General Surgery Residency Rev. July 2013
Policy on Resident Supervision University of South Florida College of Medicine General Surgery Residency Rev. July 2013 Policy Definitions: 1. Resident: A medical school graduate who is enrolled in the
More informationRegions Hospital Delineation of Privileges Family Medicine
Regions Hospital Delineation of Privileges Family Medicine Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and
More informationRegions Hospital Delineation of Privileges Pulmonary Medicine
Regions Hospital Delineation of Privileges Pulmonary Medicine Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and
More informationClinical Privileges Profile Nurse Practitioner. Kettering Medical Center System
Printed Name Clinical Privileges Profile Nurse Practitioner Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested.
More informationDEPARTMENT OF HEALTH NO No. R. 11 NOVEMBER
Health, Department of/ Gesondheid, Departement van 1390 Health Professions Act (Act 56 of 1974): Regulations Defining the Scope of Practice of Clinical Associates 40414 Reproduced by Sabinet Online in
More informationUNMH Neurology Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective May 20, 2016: Initial Privileges (initial appointment) Renewal of Privileges (reappointment)
More informationThe Greater Dayton Area Hospital Association (GDAHA) Nursing Student Experience
The Greater Dayton Area Hospital Association (GDAHA) Nursing Student Experience Current Situation: Student nurses have clinical experiences in every hospital within the Dayton and surrounding areas. Each
More informationACADEMIC GROUP PRACTICE AND THE LEADERSHIP OF APRN S
ACADEMIC GROUP PRACTICE AND THE LEADERSHIP OF APRN S Margaret Head, Chief Operating Officer/Chief Nursing Officer Susan Moseley Gent, Administrative Director Vanderbilt Medical Group March 10, 2012 With
More informationInstitutional Handbook of Operating Procedures Policy
Section: Admission, Discharge, and Transfer Institutional Handbook of Operating Procedures Policy 9.1.29 Responsible Vice President: EVP & CEO Health System Subject: Admission, Discharge, and Transfer
More informationCOBAFOLIO: DOCUMENTING THE EVIDENCE OF COMPETENCE
COBAFOLIO: DOCUMENTING THE EVIDENCE OF COMPETENCE (2006) The CoBaTrICE Collaboration: 1 st September 2006. European Society of Intensive Care Medicine (ESICM) Avenue Joseph Wybran 40, B-1070,Brussels.
More informationThe College of Nurses of Ontario presents Controlled Acts: An Overview.
The College of Nurses of Ontario presents Controlled Acts: An Overview. 1 You hear a lot about controlled acts, but do you actually know what they are? The Regulated Health Professions Act, 1991, defines
More informationSUTTER MEDICAL CENTER, SACRAMENTO Department of Family Medicine Delineation of Privileges
To request Privileges, please place an X in the request column. In box, indicate the number of identified procedures performed in previous 24 months from any Request Privilege Appointment [ ] Admit [ ]
More informationPEDIATRIC ENDOCRINOLOGY CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 04/03/2013. Applicant: Check off the Requested box for
More informationInferior Vena Cava (IVC) Filter Retrieval with the Endovascular Laser Sheath
If you have any questions, ask your doctor or nurse. Inferior Vena Cava (IVC) Filter Retrieval with the Endovascular Laser Sheath The inferior vena cava (IVC) is a large vein in your abdomen that brings
More informationReturned Missionary Study Guide
Returned Missionary Study Guide Skills to Refresh if Returning to Capstone: 1st Semester skills Head to Toe Assessment (Need to be able to document each of these.) o Vital Signs BP Pulse Respirations Temperature
More informationObservations of Off Unit Clinical Experiences for Students
Observations of Off Unit Clinical Experiences for Students This reference has been assembled to assist school of nursing instructors in pursuing appropriate patient experiences and observations for their
More informationThe Ohio State University Department of Orthopaedics. Residency Curriculum. PGY1 Rotations
The Ohio State University Department of Orthopaedics Residency Curriculum PGY1 Rotations Goals and Objectives Anesthesiology Rotation PGY1 Level I. Core Competency Areas By the end of the PGY1 rotation
More information393 PICC INSERTION USING ULTRASONOGRAPHY AND MICRO INTRODUCER TECHNIQUE 06/10/03 1
393 ULTRASONOGRAPHY AND MICRO INTRODUCER TECHNIQUE 06/10/03 1 POLICY: General Information: 1. RN s validated to insert PICCs with the additional training in the use of ultrasonography (U/S) and microintroduction
More informationINPATIENT Annual Core Competency Performance Stations (Nursing) 2010 (Unlicensed Staff Direct & Non-Direct Care Providers * )
County of Los Angeles INPATIENT Annual Core Competency Performance Stations (Nursing) 2010 (Unlicensed Staff Direct & Non-Direct Care Providers * ) * Staff who work in patient care areas 1 ANNUAL CORE
More informationSupervision of Residents/Chain of Command
Supervision of Residents/Chain of Command Creighton University Department of Surgery Residency Training Program Chain of command for Surgery residents at CUMC PGY1: The intern on call covers the two general
More informationPeripherally Inserted Central Catheter
UW MEDICINE PATIENT EDUCATION Peripherally Inserted Central Catheter Understanding your PICC procedure and consent form Please read this handout before reading and signing the form Special Consent for
More informationHospitalist Medicine Clinical Privileges
Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,
More informationPeripherally inserted central catheter (PICC line) Information to accompany consent
Peripherally inserted central catheter (PICC line) Information to accompany consent Exceptional healthcare, personally delivered What is a PICC line? PICC stands for peripherally inserted central venous
More informationSUPERVISION POLICY. Roles, Responsibilities and Patient Care Activities of Subspecialty Residents (Fellows)
Roles, Responsibilities and Patient Care Activities of Subspecialty Residents (Fellows) Definitions Pediatric Critical Care Medicine Fellowship Program Seattle Children s Hospital and Harborview Medical
More informationGuidelines for Supervising Residents Updated July 2017
NORTHWESTERN UNIVERSITY FEINBERG SCHOOL OF MEDICINE DEPARTMENT OF SURGERY POLICIES & PROCEDURES Guidelines for Supervising Residents Updated July 2017 PURPOSE To clearly define the level of patient care
More informationPediatric Cardiology Clinical Privileges
Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,
More informationTo ensure oversight of resident supervision and graded authority and responsibility, the following levels of supervision are recognized:
Roles, Responsibilities and Patient Care Activities of Residents University of Washington Boise Internal Medicine and Saint Luke s Health Care System and Saint Alphonsus Health Care System Definitions
More information