Effective Dates: 2/2/2014-2/1/2016
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1 Effective Dates: 2/2/2014-2/1/2016
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17 AHP Clinical Privileges Update Form John Cardwell, PA Department of Lynchburg Nephrology.L 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. Dat. S?~~ ~~~ra~c~t~it~io~~~e~r-'s~~-i-gn-a-t-u-r-e '~-" -, 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: --~ ~ Medical Record Review &' Continuing Education Conferences 0 Annual Evaluation Student Evaluation u( Physical & Mental Health related to Job Performance 0 AnnuaJ Review by Dept. Chair or SCA [l Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: ~cceptable review with recommendation of reappointment with clinical privileges as requested. Mohammed Ashraf. M.D. Printed Name Asad Ehtesham, M.D. Printed Name ~,; J6fOSm" RJ.j) "81i&~a ihii&falfl, M.Q, Printed Name ~ /,JIlu.tttd I IYI.P Printed Name ~ S. ~'ni".tr/,fj..j) pri=~, revised 3/1/2005 ~ oj I#I~
18 Privilege List for: Physician's Assistant 02-Dee-08 Name: ~6~/ Date: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE A The applicant will not undertake patient management except in emergency. B The applicant will manage patients with physician present. C The applicant will manage patients in collaboration and/or consultation with the physician,.. rocedure ''"";eneral,jeneral Anesthesia Local Arterial line placement Bronchoscopy Cath Swan Ganz catheter placement Catheter - IV Peripheral - Placement & Mgt Chest Tubes - Insertion ECG Administration Feeding tube Placement Halo Vest - Adjustment Halo Vest - Pin Care & Mgt Halo Vest - Placement IABP - Placement & Management Injections Injections Injections - Intradermal - Intramuscular - Intravenous Insertion, Catheter - Bladder Intradermal Intubate IV Medications Lumbar Puncture Mini Tracheostomy NG Tube Insertion Place trans-venous Skin Testing & Fluids - Administration pacer Re-open Explore Chest Surgery Assist - 1st & 2nd Assisting Surgery Assist - Harvesting Vein Surgery Assist - Position & Prep Suturing Suturing Thoracentesis Venipuncture - Major - Minor Venous cutdown Wound Mgt - Debridement Wound Mgt - Removal of Sutures/Staples Evaluate Evaluate Evaluate Evaluate Evaluate Evaluate History - ECG - Echocardiogram - EEG - Holter Monitoring - Labs - Radiographs and Physical c,v e.v Neonata I Ped Ad 0I Ad uti G' ertatric 'izjii" ~ 1.8,,/ BVe/ ~V'" c /'ICV Cv C"'- -(; v--' CY"" C,./ CV ~ {,./ eeḷ /1 I~,/ vel i I i " i Cv" (;V ; C,/ [,v Cv" {;v' I C V CI/ 7.,/'.;: ~?V' C." J i I
19 -,-- ;eneral OTHER Hospital Rounds Order - Diet Order - ECG Order - Echocardiogram Order- EEG Order - EMG Order - Holter Monitoring Order - Labs Order - Radiographs Order Consults Order Medications Patient Education PRIVILEGES Neonata I Ped Ad 0I Ad uit G' eriatrjc ;/fj vjj Cv Ie c-: I:~ C/ r:v' C -,,/ -. :.... / C V C v C' c./ t:-"" r.,/ c,.v C C. V (1t/ c..v c. V c:v..,. C,/ c.."" DATE As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the abovenamed practitioner's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named practitioners qualifications are appropriate. DATE Primary Supervising Physician Signature Name Printed -"""Ltt""""u.J~e""""a~($/I'tflitff DATE DATE Name Printed DATE \' ilp I o~ Alternate Supervising Physician Signature Name Printed DATE Dept Chair or Clinical Administrator Name Printed
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
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