|
|
|
- Elwin Preston
- 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 Allison Walton, FNP AHP Clinical Privileges Update Form Department of Neurosurgery 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): Practitioner's Signature.r=>; As the Supervising Physician/QI LiaisonfDepartment Chairl 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: o Record Review Annual Evaluation ~ Continuing Education Conferences 0 Student Evaluation ~ Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA o yisk Management Events/Quality Management Reports for claims [id'"prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: ~ ~ Acceptable review with recommen. n of reappointment with clinical privileges as requested. o Concerns noted on revie as requested, but subje q\2-~f t;~ ~\t..~\,,~ Aaron Dumont, M.D. Date f Printed Name ~ tj1(()-}j9 orr ave action plan in place with recommendation of reappointment with privileges vfn months. Neal Kassell, M.D. Printed Name John Jane, Sr., M.D, Printed Name Date Alternate Supervising Physician Signature Printed Name ~ Date t,,\ Il0'\ cs Administrator (for Me employees) Printed Name Mark E. Shaffrey, M.D., Chair irector Signature (for HSFemployees) Printed Name revised3/1/2005
35 AHP Clinical Privileges Update Form I have reviewed the privileges previously granted (copy attached) to me and request t New Privileges to be Added (please indicate category level and type of experience): I 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. pri i1egesare 0 be repo d as voluntarily relinquished you will be notified and recei e a copy the report to be filed with the National cf' r Dat k. Practitioner's Signature As the Supervising PhysicianlQI LiaisonlDepartment Chairl 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 qualiflcations are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~... Record Review Annual Evaluation ff )Zontinuing Education Conferences 0 Student Evaluation ~Yhysical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA (g'"...-riskmanagement Events/Quality Management Reports for claims 0' Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other We find as follows: ~cceptable review with recommendation of reappoi ace with recommendation of reappointment with privileges ~ D~te ' l{ji%.\0'" Printed Name -:Id""D ~":S('. ~ Printed Name \ I ~1>~~ Printed Name I l Date Alternate Supervising Physician Signature Printed Name Date Administrator (for Me employees) ~ Printed Name ) I revised 3/1/2005
36 ,", 'L-UIU'-41 J: IIYIU::g,\;:s uljuatt: rorm _A_t =---ll.s=-::..()_h.--,--uj-=---~-----,f._o_n..l--_department of --+--l-'o~--'-=.;~=---.::..::l~:---v::=---- I have reviewed the privileges previously granted (copy attached) to me and qu 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 pro eding. If privileges are to be reported as voluntarily relinquished you will be notified and recei e a co y of the report to be filed with the N ti Practi ner a bank. Date As the Supervising Physician/QI Liaison/Department Chairl 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: ~ j Record Review Annual Evaluation ~ ~ontinuing Education Conferences 0 Student Evaluation Q/-Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA g...-riskmanagement Events/Quality Management Reports for claims Ii2" Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other ~ We find as follows: ~ Acceptable review with recommen o Concerns noted on revie as requested, but subject Date' of reappointment with clinical privileges as requested. i 2.-\ '->. \ C)Sive action plan in place with recommendation of reappointment with privileges n months. sing Physician Signature ~~ \.".to..z~\\ kab. Printed Name I Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physlcian Signature Printed Name Date Service Cntr A Printed Name D'ate" Chair/ anal AI ::JC) Y\f\..f\ "3:;'~~...5r re ( r HSFemployees) Printed Name I ~"JR/VJ \'&th ~faf{ C(C<. ~ revised 1/8/2003 \
37 Privilege List for Family Nurse Practitioner 23-Feb-05 Name: A t.,.l-f.sch Date: 1:11:~f cr5 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 WIDCH 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. ->">, ~, Anesthesia Regional Pulmonary Function Testss EMG Audiometry Tonometry Slit Lamp Exam Spirometry Percutaneous PAP Smear Fetal Monitoring IncisionlDrainage Skin Laceration Anoscopy Sigmoidoscopy EMG Biofeedback Arthrocen tesis Arterial Blood Gas Bone Marrow Paracentesis Thoracentesis CPR Endotracheal Circumcision Skin Testing of Abscesses Repair Aspiration Intubation Norplant Insertion & Removal Breath Hydrogen Test Cryotherapy Lumbar Puncture Foreign Body Removal - Subcutaneous / Foreign Body Removal - Subungual Congenital Heart Disease Rheumatic Heart Disease GI Disease Dif Dx & Tx Premature Disorders Dx & Tx Premie Growth & Development Neurological CNS Infections Psychophysiologic Renal Dif Dx & Tx Dif Dx & Tx Dif Dx & Tx Electrolyte & Water Balance Croup, epiglottitis. Neonatal Ped Adol Adult Geriatric c. c. < <, c c c c. t. e, C, <: c. r. C,, A A A A A A A A c, '- c, t ~ ~ <: ( t {' ~ ~ e ~ C C I' ( l <: ( c. c, <:. t ~ c. Co e, c ~ ~ C!. c e, <:. c Q ~ Q. (I t ( ~ Page 1 of 5
38 ,~,~ ~, Cystic fibrosis Pulmonary Dif Dx & Tx Pre & Post Op Cardiac Attention Cerebral Care Deficit Disabilities Palsy Head & Spinal Cord Injury Ped Learning & language disabilities Ped Mental retardation Pituitary Conditions Malabsorption Immunization Osteoarthritis Rheumatoid Rheumatic Cardiac Peds Dif Dx & Tx Arthritis Fever - Acute Rehab Neurodegenerative Endocrine/Metabolic Disorders Dif Dx & Tx. Med Dif Dx & Tx Allergy/Immun Die Dx & Tx Arthritis Cardiovascular Birth Defects Eval Newborn DifDx & Tx Newborn Adjustment Ped Behavioral Cognitive Dialysis screening Dif Dx & Tx Problems Rehab Mgt Rheumatologic/Vasc HIV,AIDS Immunodeficiency Health Geriatric Cholecystitis Pancreatitis Cirrhosis Maintenance Problems Dif Dx & Tx Dif Dx & Tx Hepatic Diseases Dif Dx & Tx Gynecologic Routine Dif Dx & Tx Infertility Initial Eval & Mgt Sexual Counseling Infectious Disease Dif Dx & Tx Diabetes Mellitus Fractures & Dislocations Pediatric Emotional Disorders Dermatologic Diseases - Dx & Tx Drug Reaction & Overdose CVA Rehab Anesthesia Local Foreign Body Removal - External auditory Foreign Body Removal - Vagina Wound Mgt Assess for Functional Integrity Pulmonary Artery Catheter Manipulation Wound Mgt- Wound preparation Wound Mgt- Debridement Wound Mgt. Closure Wound Mgt Dressing Wound Mgt. Immobilization Neonatal, Ped Adol Adult Geriatric t ~ c ~ Q ~ ~ ~ ~ c ~ ~ t. e, 0.- e, e. <:. c. ~ Co c, <:. c c ~ ~ ~ Co ~ c ~ c. '- ( ~ C c: c. Q ( <!. Q ~ ~ <:. c. e ~ c: ~ ~ c ~ c, ~ C c Q \:. c c Q ~ ~ o C c: <!.. C c:: ~ ( "- ~ <: c ~ c (' ~ Q c t e. C c <:. e ~ ~ C (' c. ~ <: C' c ~ e Q C C C C' c C' c C ~ ~ o c <' Q C < C <: <!. c (. Q. c. 0 r c e <: < c ~ c c, (' (' C' c ~ (' C Q c c e, r C c: r c C c o C!. <:. Q t Co C. c c c (' c e c c \ c c c (' c C c C Page 2 of 5
39 _~. '-~'. Nail Avulsion IUD Insertion & Removal Pessary Insertion & Removal Allergen Histamine Immunotherapy Provocation Wound Mgt. Removal Prenatal Counseling Impotence. Evaluation & Mgt Pain Management History and Physical Ox, Assessment & Mgt Telephone Triage/Consultation Hospital Rounds of Sutures/Staples Admissions (with MD collaboration) Order- Labs Order- Urodynamic Studies Order - ECG Order Echocardiogram Order- Holter Monitoring Order- EEG Order Order Order Radiographs Consults Medications Nutritional Status- Eval & Mgt Peripheral Central Venous Line Placement Contraceptive Counseling Health Maintenance & Disease Prevention Cerumen Impaction Removal Ventilator Weaning Mgt Chemotherapy- Intradermal POIIVlIntrathecal Skin Testing Lab Test- Dipstick Urinalysis Lab Test - Cervical Cultures Lab Test- Urethral Cultures Lab Test - Rectal Cultures Lab Test- Throat Cultures Lab Test Soft Tissue Site Cultures Lab Test- Blood Cultures- Draw Surgical Assist Surgical Drain Removal Tracheostomy Tubes Remove Transtracheal Aspiration Wound Mgt Electrocoagulation OB Routine Prenatal & Postpart Eval & Mgt OB. Intermed. Risk Prenatal & Postpart Eval & Mgt OB High Risk Prenatal & Postpart Eval & Mgt 'cardiac Arrest- Assist Colposcopy. Cervical BiopsylECC Condyloma Tx's Microscope Eval- Urine Microscope Eval Post Coital Cervical Mucous Microscope Eval Breast Discharge Microscope Eval Amniotic Fluid Intermittent Catheterization Tx Ultrasound Fetal Ltd Fetal Presentation Ultrasound. Fetal Ltd Fetal Cardiac Activity Ultrasound - Fetal Ltd > Dating 1st Trimester Ultrasound. Fetal Ltd AFI Neonatal < Ped Adol Adult Geriatric (' c. c c c c. ~ c C' (\ ~ ~ c. (' ('" (' (' <: ~ c ~(' c C c c. (. c. ~ c. c Q c c c c ('" c C ~ c c (' C' c c c ~ 0 ~ C (' Q C C <: ~ c C. c, C c:. ~ c c (' c C'. o c <:. (' c c c c o c o ~ 0 (I o C r C- eo <!. (' C c c. c c t' c ~ <:: c c C' (' c.. c " <: ~ C o ( <:. C < c A A A A c, c c. ~ c, \.. e. < Page 3 of 5
40 Neonatal Ped Adol Adult Geriatric.~ Urodynamic Studies - Simple Office Cystometrics Urodynamic Studies - Urodynamic Catheterization Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Percutaneous EMG Gouty Arthritis,. rcp Adjust Treatment Protocols Heme/One Dif Dx & Tx Hyperbilirubinemia Spinal Shock - Mgt Thrombophlebitis Urologic Urticaria Disease - Dif Dx & Tx Adjust Pacemaker Settings Adjust Cardiac Assist Devices Ambulatory Camino Halux 02 Saturation Bolt Removal Hansel Smear - Nasal Secretions Intracardiac Catheter Removal Omaya Reservoir TPN Ordering Typanometry Ventricular Catheter Removal Conscious Diaphragm Sedation Fitting Biopsy - Endometrial Chest Tubes - Clamp and/or Remove Epicardial Pacing Wire Removal Doppler Monitoring of Fetus Ortho s - Nasal Ortho s - Ribs - Stable Chest Ortho s - Shoulder Dislocation Ortho s - Clavicle Ortho s - Upper Extremities Ortho s - Lower Extremities Pulmonary Artery Catheter removal Biopsy/Removal Biopsy - Vulvar - Skin Lesion Foreign Body Removal - Nasal Lab Test - Vaginal Cultures Serum Sickness Microscope Eval - Vaginal Secretions Authorized Evaluate Evaluate Evaluate to Prescribe - ECG - Echocardiogram - EEG Evaluate - Holter Monitoring Evaluate - Labs Evaluate - Radiographs Evaluate - Urodynamic Studies Dermatomyositis Nephrotic Disease Dif Dx & Tx c.. <:. c. < c o (' c o ~ c ~ ~ ~ <:. c. c C ~ ( c, c. c. c c. c c. " C r C C c. r c ~ c <: ~ o c c c C c C c c C'_ c. c e L c. ~ ~ c. e, C. \ c c. (' c c, C- (' C. C C. c, c c. c. c. c c. c C- e. c. C C- c <: c C. e r C t e. e. C c. r Page 4 of 5
41 OTHER PIUVILEGES Neonatal Ped Adol Adult Geriatric ~(~05~ _ DATE LlliJ-----'-QJb,,-----,o--_A_L-L---=-/~ --,-'"_VJ. _lrk_lt_orj Signature Name Printed 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 pracf on rs qualifications are appropriate. n1a'z-~105 ~l '2..crl ()S DATE Name Printed DATE Name Printed DATE Alternate Supervising Physician Signature Name Printed DATE Dept Chair or Svc Center Administrator Name Printed Page 5 of 5
AHP 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
AHPClinical 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
AHPClinical 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:
Regions 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
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
APP 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
NEONATAL-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
Clinical 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
UNMH Family Medicine Clinical Privileges
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 07/31/2015 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.
UNMH Family Medicine Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective April 28, 2017: Initial Privileges (initial appointment) Renewal of Privileges (reappointment)
Supervision 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
INSTRUCTIONS 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
PEDIATRIC 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
CLINICAL 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
Privileges 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,
Delineation 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
UPMC 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
CRITICAL 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.
Qualifications For initial appointment and core privileges in the Department of Family Medicine, the applicant must meet the following qualifications:
DEPARTMENT OF FAMILY MEDICINE Qualifications For initial appointment and core privileges in the, the applicant must meet the following qualifications: Successful completion of an ACGME or AOA-recognized
FAMILY MEDICINE CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 4/3/2013. Applicant: Check off the Requested box for
SPECIALTY SPECIFIC OBJECTIVES
Family Medicine Residency Internal Medicine In-house II Rotation Rotation Goal Admission, evaluation, treatment and appropriate specialty consultation of adult hospitalized patients from either the ER,
Regions 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
-.. AHP linial Privileges Update Form NAME: 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:
INTERNAL MEDICINE CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 11/20/2015 Applicant: Check off the Requested box for
Privilege 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
GENETICS 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
APP 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
General 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:
Regions 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
PEDIATRIC 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
UNM 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
CARDIOVASCULAR 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
PEDIATRIC 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
ADOLESCENT 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
SPECIALTY 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
SCOPE 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
PRIVILEGE APPLICATION FORM - [Mercy Medical Center]
![PRIVILEGE APPLICATION FORM - [Mercy Medical Center]](/thumbs/85/91362180.jpg "PRIVILEGE 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 =
NEPHROLOGY CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 02/15/2017 Applicant: Check off the Requested box for
Huntington 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
PULMONARY 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
UNM 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
Nurse 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
Family Medicine/General Practice 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,
Leading Practices and National Benchmarks in Advanced Practice Clinician (APC)
Leading Practices and National Benchmarks in Advanced Practice Clinician (APC) Privileging, Competency Assessment and Leadership Structures Presented to: National Credentialing Forum March 2, 2017 Trish
Policy 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
DEPARTMENT 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
UNMH 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.
PEDIATRIC 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
DELINEATION OF PRIVILEGES - FAMILY MEDICINE
KALEIDA HEALTH Name DELINEATION OF PRIVILEGES - FAMILY MEDICINE LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency
APPLICATION FOR CLINICAL PRIVILEGES (MEDICAL)
APPLICATION FOR CLINICAL PRIVILEGES (MEDICAL) Granting, reviewing, and changing of clinical privileges for the staff of FIRST CHOICE COMMUNITY HEALTHCARE (FCCH) will be in accordance with the FCCH policy.
Clinical 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.
Med/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
Penrose-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 _ ***************************************************************
Huntington 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
Loma 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)
Regions 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.
DEPARTMENT 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
B. Appoint a board-certified emergency physician as medical director and an emergency medicine physician assistant as program director.
Society of Emergency Medicine Physician Assistants (SEMPA) Emergency Medicine Physician Assistant Postgraduate Training and Emergency Medicine Physician Assistant Practice Guidelines I. The Society of
DEVELOPMENTAL-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
SUTTER 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 [ ]
Critical 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,
MD or DO or equivalent International medical training
UPMC 1 Delineation of Privileges Request Criteria Summary Sheet Facility: Specialty: Childrens Hospital of Pittsburgh of UPMC, North PEDIATRICS KNOWLEDGE MD or DO or equivalent International medical training
Credentialing Application Packet. Dear Resident Applicant,
Credentialing Application Packet Salina Family Healthcare Center A Federally Qualified Community Health Center 651 E. Prescott, Salina, KS 67401 Medical Center ~ (785) 825-7251 Dental Center ~ (785) 826-9017
Supervision 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
CRITERIA FOR GRANTING MEDICAL PRIVILEGES
CRITERIA FOR GRANTING MEDICAL PRIVILEGES Please review these categories carefully to determine those privileges for which you are qualified. Indicate your request below by checking the appropriate category.
EMERGENCY MEDICINE CLINICAL ROTATION COMPETENCY BASED CURRICULUM
CLINICAL ROTATION COMPETENCY BASED CURRICULUM EMERGENCY MEDICINE During the third year of the curriculum, students expand their knowledge of emergent conditions and gain the ability to apply the knowledge
To 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
Metropolitan Chicago Healthcare Council (MCHC)
Emerging Trends All APNs Should TITLE Know OF to PRESENTATION Practice at Their License LORUM Ceiling IPSUM DOLOR October 10, 2014 Molly Harper, MHA Program Manager, Clinical Services Metropolitan Chicago
N: Emergency Nursing. Alberta Licensed Practical Nurses Competency Profile 135
N: Emergency Nursing Alberta Licensed Practical Nurses Competency Profile 135 Competency: N-1 Multi-Systems Assessment N-1-1 N-1-2 N-1-3 N-1-4 Demonstrate knowledge and ability to apply critical thinking
Physician Application
CONTROLLED RISK INSURANCE COMPANY OF VERMONT, INC. (A RISK RETENTION GROUP) CONTROLLED RISK INSURANCE COMPANY, LTD. Physician Application Please type or print responses in ink, and answer all questions
Family Medicine Residency Surgery Rotation
Family Medicine Residency Surgery Rotation Rotation Goal The overall goal for the educational experience provided in the areas of general surgery, trauma surgery, office orthopedic surgery and sports medicine,
UWSMPH Clerkship Experience Requirements
2016-2017 UWSMPH Clerkship Experience Requirements Students will use OASIS to check off each Clerkship Experience Requirement. The following conditions, procedures and learning activities must all be completed
Basic Standards for. Residency Training in. Osteopathic Family Medicine. and Manipulative Treatment
Basic Standards for Residency Training in Osteopathic Family Medicine and Manipulative Treatment (Includes Rural Training Standards in Appendix III) American Osteopathic Association and American College
Pediatric Intensive Care Unit Rotation PL-2 Residents
PL-2 Residents Residents are required to have sufficient knowledge of their patients in order to present them to the team on rounds, and to construct a differential diagnosis and treatment plan. They are
Policy on Supervision: Roles, Responsibility and Patient Care Activities for Residents. Department of Medicine Internal Medicine Residency
Policy on Supervision: Roles, Responsibility and Patient Care Activities for Residents Department of Medicine Internal Medicine Residency Philosophy Residents are physicians in training. They develop and
Martin s Point US Family Health Plan Pre-Authorization Requirements
Martin s Point US Family Health Plan Requirements Requirements described below are for covered benefits only and this information is provided for summary purposes only. Please call 1-888-732-7364 for complete
I: 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
During the hospital medicine rotation, residents will focus on the following procedures as permitted by case mix:
Educational Goals & Objectives The Inpatient Family Medicine rotation will provide the resident with an opportunity to evaluate and manage patients with common acute medical conditions. Training will focus
Hospitalist 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,
NURSE 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:
Trauma Rotation UMASS Memorial University Campus
Trauma Rotation UMASS Memorial University Campus * The following objectives include goals and achievements set forth for successful completion in the acute surgery & trauma rotation such that residents
The University of Arizona Pediatric Residency Program. Primary Goals for Rotation. Anesthesia
The University of Arizona Pediatric Residency Program Primary Goals for Rotation Anesthesia 1. GOAL: Maintenance of Airway Patency and Oxygenation. Recognize and manage upper airway obstruction and desaturation.
Skills/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
APP 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
LICENSURE, CREDENTIALING, AND GRANTING OF CLINICAL PRIVILEGES
Licensure, Credentialing, and Granting of Clinical Privileges Chapter 6 LICENSURE, CREDENTIALING, AND GRANTING OF CLINICAL PRIVILEGES Joanna G. Sanford, PA-C, MPAS Introduction US Army physician assistants
Clinical 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,
PRACTICAL 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
DELINEATION 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
Privileges for San Francisco General Hospital
Applicant: Please initial the privileges you are requesting in the Requested column. Service Chief: Please initial the privileges you are approving in the Approved column. MedGI GASTROENTEROLOGY 2008 (0808
Regions 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
Basic Standards for. Residency Training in. Osteopathic Family Medicine. and Manipulative Treatment
Basic Standards for Residency Training in Osteopathic Family Medicine and Manipulative Treatment (Includes Rural Training Standards in Appendix III) American Osteopathic Association and American College
UNMH Pediatric Nephrology Clinical Privileges
ll new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 07/31/2015 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.
ABOUT THE CONE HEALTH NETWORK OF SERVICES
THE MOSES H. CONE MEMORIAL HOSPITAL (536 beds) Critical Care Services All system ICU patients are monitored with the help an electronic ICU monitoring system (VISICU ). Emergency Services Medical Intensive
Department of Emergency Medicine. Department of Family Medicine. Department of Internal Medicine
Emergency Medicine Students per rotation: 5 Department of Emergency Medicine Medical students are expected to work 40 hours per week. Shifts are divided evenly between days, evenings, three night shifts
E: Nursing Practice. Alberta Licensed Practical Nurses Competency Profile 51
E: Nursing Practice Alberta Licensed Practical Nurses Competency Profile 51 Competency: E-1 Critical Thinking E-1-1 E-1-2 E-1-3 Demonstrate knowledge and ability to apply critical thinking concepts throughout
Surgical Treatment. Preparing for Your Child s Surgery
Surgical Treatment Preparing for Your Child s Surgery If your child needs an operation, it will be performed at a hospital that has special expertise in heart surgery for children. This may be a hospital
2016 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
SPECIALTY OF FAMILY MEDICINE Delineation of Clinical Privileges
SPECIALTY OF FAMILY MEDICINE Delineation of Clinical Privileges Criteria for granting privileges: Current board certification in Family Medicine by the American Board of Family Medicine or the American
2018 DEADLINE DATES FOR DELEGATION AGREEMENTS WITH ADVANCED DUTIES
2018 DEADLINE DATES FOR DELEGATION AGREEMENTS WITH ADVANCED DUTIES These deadline dates pertain to PAs submitting delegation agreement addendums for advanced duties who are either: Employed by an accredited