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10 Clinical Privileges Update Form ~ U - RSr1yl q RGINIA I Glen Michael Department of Emergency Medici i HEALTH ~M I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:* - j*privileges not renewed are not reported as being voluntarily' reli~q~i;hed unless this is done while you are under investigation; lor, in return for not conducting an investigation or proceeding Ifprivileges are to be reported as voluntarily relinquished you twill be notified and receive a copy ofthe report to be filed with the National Practitioner Databank ~NSIGN;URE As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate Since the date ofthe last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We ~follows: J2Sl ~cceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested Concems noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months Should have clinical privileges granted but restricted as follows: DATE fj)qj:)yy~,r ~~, DlvlSloN HEAD/QI LIAISON ~ DATE DEPARTMENT CHAIR SIGNATURE Revied 3/1/2006
11 'i <Slcl\ Name u cs F Medical School REQUEST FOR CLINICAL PRIVILEGES Department of Emergency Medicine University of Virginia Health Sciences Center 6:"" M\clAae-\ 2-CX::>i and Year of Graduation U V'A; I::~~c;-~fV\<:cllci!\C '2-0\= Residency Training Location and Years Fellowship/Post-Residency rr<+itjing Location and Years Board Certification(s) in Year(s) of ({artification CategorY A CategoryB Cateqory C Admit-to Emergency Department Observation' Status ~ Yes ONo PLEA$EMARK AS REQUESTED ONt Y THO E "AREASWHI;RE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EM6RGENCY PRIVILEGES SHOULD BE MARKEDWHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA tn WHICHYOPPONpTHEGULARCy PRA9T1yE AR EAS INWHICH YOU DO NOT REGULARLYPRAQTIGE SHOULbsELEFT S(ANK I MEDICAL According tc? G'q,tegory,'flnterA, Bote mth~recjuestepqgli1rrll:,-- : -_--- :! ;--~ ; '- -_ - -,- " -,: - " - - -,---, I --, c- --, fheapplicari+wifl hot ubdertakepatientnimagerh~[)f~xceptib er11etgehcy '--; ' _ - " ' -, ;: The applici;lnt will Qc~a~ionallymanag~patients6r assist in manaqement, Consultation win besought in the event of antic;patector aotualqift[cultie$ ' ':~E ~~~'~~~~~~~~f~+,:,;,:,,4, Traurna!,,, " 11 ; p:sych'i~t'rite~otioha\'dj:so;:de rs ;' C " " I ToxicokigyL En vi'ro'ilmentai"cii sord'e rs :, " c ; 'Dr~enfc ~Fe: ' ', : z;,,
12 Acute medical conditions Acute atraumatic surgical c conditions : HISTO~ ANDPHYSICALEXAMINATION: PEDIATRIC EMERGENCY MEDICINE T~~: _, Psychiatric-Emotional ~ - disorders ~ ~ c To~icoiog~=E n ~ fr o h ;;:i~~ta i d iso~d~~s ~,; ~ ~ ;,, Urgent care Co ECGINTERPRET ATION Co LABORATOHY STUDIES INTE~PRET ATION IMAGING STUDIES INTERPRETATION c Musculoskeletal radiographs _~~~ ~ AND CORRELATION TO CLINICAL CASE ~ - n C, '~ ~- ~ I " ~ ~~~~~~~,~~~, b Compl,Ited tom()qraphy,;,~ ~ n_ ~ - ' ) C) - ~ ; Fluoroscopy PHYSICIAN-PATIENT COMMUNICA TIONI PSYCHOSbCIAL SKILLS c COORDINATION SERVICES' c OF CONSuLTATION OTHER ' ; --! -~, ~ -, :~~ U'" ~~ ~, _,The applicantwill not ohdertak~the u ~ ~ ; ~ ~ ~ - - ~7", The applicant wiu occasionajlypenorm OF assist inthe perfflrm~n c~pf the procedure Con$ultatiqn willbe sought in the eve fit ofanticipatedqr acttiali:jifficulties, Categor\l C fh~ applicant will perforrnth procedure only QccaSionaIlY I According' tofyp~,,~nter1" Type'1 t ~; pt~cedu(e except inernergen&y- Category B consultation : The applicant woyldbe expectedto recjuest j2; ot 3 in the ~XPERlENC(c,olumi1,CpiT)plete~ Fo;rrn31' Trai1'lingPto9"~rn" J ~::;~, :;;:g;~;~r~;;~~;j~~tj;~~,j ACLS:EME~GENCV' RESUSCI,TA TI()N -- OF PATIENTS MLJCnPLETRA UMA RESUSCITA'nON/ST~BILlZA AMBULATORY SEDATiON lion S~~~E!?~~ ~~~~~~~~ Oeepsedation " ~ G I
13 Sedation Maintenance for Tracheally Intubated Patient C AIRWAY SKILLS Cricothyrotomy G v Tracheostomy _, Rapid sequence induction for intubation C ' ~ - u - _ - Endotracheal intubation ~! Orotrachealintubation c, J Naso-tracheal intubation L I ~ ~~~~~~~~~~~;,,, ~ ;, ;! ;, Manual assisted ventilation (BVM) C ~ Percutaneous trans-tracheal ventilation '- - ~~,~; -~, ~~ ~ ~~- " ~ ~~ "' ~" Obstructed airway maneuvers C J O~yge ~ d~ii~ ~ ~y ; Z T ' ANESTHESIA Local ~ ; ~ ) - ~ - -- Regional ARTHROCENTESIS URINARY BLAD[)ER ACCESS/ CATHETERIZA TIONllRRIGATION Foley catheter insertion - ~- ~ - ; - ~,; - ',- - Suprapubic bladder aspiration c, I CARDIAC MASSAGE Open C \ cios~ d c i L' CARDIAC ELECTRO CONVERSION CARDIAC ELECTRICAL PACING Transvenous Co CULDOCENTESIS ELECTRQGOAGULA TION T ~~~s~;j\~~~o~s ' L ; - - ~ _ Transthoraclc- ( - FOREIGN BODY REMOVAL Supcutaneous: < I S u b uhg u ~i ' ' : c:, j Extenialauditorv caflal/n~rves '", ' C;;;:h~a/C'o nj~hcti ~~~ ', z ; ::!~pe~:~;~:~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::5::::::::::::::::: ::::::::::::::::::::::::::::::::::::: Vagina' '-- I :Oth~;: ' ' ', ~, FRACTURE/DISLOCATION R~~uqtiofl t' '- I ' i"th;t ;;r;iii~~ ti;;ri :r ', 2:: j" GASTRIC TUBE INSERTION INCISION/DRAINAGE INTRA CARDIAC LUMBA8 PUNCTURE MAST TROUSERS INJECTION : Nasog~S:~rictu~e <: I' O(o~~st rj"c "tub~ fo~ g:a stric ia ~ ag~ C ' ; Application R ~ iri o~~i ~: - ~ ~ ~ ~ NASOPHARYNGOSCOPY c, <
14 NASAL PACKINGICAOTEIW NAIL TREPHINATION/REMOVAL OCULAR PARACENTI;SIS PERITONEAL TC)NOMETRY LAVAGE PERICARIO[)CENTESIS PERICARDIOTOMY RESPIRA TOIRS Manual c: 1 < oa ~!~~~~!~ ~yp~ ~, t Volume type c, I RESTRAINTS: APPUCA TION, USE ( I S '" "COPY, PRO=rOSCOPY, NOSCOPY' SKULLTREP'H R'ING INA TION SLIT tamp:i:>iagnostic CORNEAL REMOVAL FOREIGN BODY SPINAL IMMOBILIZATION SPUNt'A~PLlCATION THORA,CENTESrs THORACOStOMY THORACOTOMY USE VASCULAR ACCESS TECHNIQUES Needlethbraco~tomy " I T ~ b e tho~~ c6~to~y (: j " I Peripheralvenolls access, ( :'\I;nQu s cutd6~n ; (: "j" Ce ~ t~~j'"v; ~ b ~ s ca n n u i~i"i on :::::::::::::::::::f:::::::::::::::::: :::::::::::::::::::::~::::::::::::: Jugular ~ ~ : Subclavian c: :, :! Femoral c I ' ~; ~~~~~;~~~~ ~ Peroutaneousarterlal access c L ::~~ti~w~~iti~:~;~~~j~~~f~e~~1~!!2~:::::::::::::::::::::::: :::::::::::::::::::::~:::::::::::::: :::::::::::::::::::::;: WOUND MANAGEMENT Ass/:lssmentfqr functional integrity C ' I ::~~:~~~jp~~~~;~;~~;~::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::2::::::::::::::: ::::::::::::::::::::t:::::::::::::: OTHER ::~t~~~~!~~:~~~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::~::::::::::::::: i"rrim 6 biiii~ti onl <: e Co Co c C I I ::::::::::::::::::::::i:::::::::::::: ::=:::::~=::f: ::==:::::::=::~,::::::::::::::::::::::::::: 1",,, : DATE ~s~/~i_~,~/l_q~o _ ~--- -:>--- -C-Ll-N-IC-,A- -N ~-----
15 -l Page 5 I ~ As Division Head/Ol Liaison and Department Chair, we have reviewed the above-named clinician's level of expenence, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that clinician's qualifications are appropriate The following indicators have been reviewed for reappointment Since the date of the last appointment, sources of quality data: we have reviewed applicable information from the following Physician's Health & Mental Status Inpatient Attending Performance Morbidity and Mortality Reports Blood Usage Reports Drug Usage, Reports Infection Reports lnvasive/non-lnvasive Procedures Medical Records Documentation Patient/Family Satisfaction Sentinel Events/Risk Management Reports Consultation Attending Performance Outpatient Clinical Practice Peer Review of Clinical Performance Other: We find as follows: Acceptable -review with recommendation of reappointment to the clinical staff with clinical privileges as requested Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months DATE \1\1\_ ' ~4' ~L~:---d--:,-C_'_\)_~ clin prier (r:03/11/05)
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,
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