|
|
- Natalie Richards
- 5 years ago
- Views:
Transcription
1
2
3
4
5
6
7
8
9
10
11
12
13 AHP Clinical Privileges Update.Form -"Da'IJi~l~~(jttipger Department of NICU r'av~'r~;vlewe&'~~epfivilegespreviouslygranted (copy attached) to me and request the following changes:.nc\v'privilaaes{obe A:dded(please indicate category level and type ofexperienee): *~li'v,j/e~~sttott~,ii~we!j~!;e.twtrfp(irted~sl>el~gvqlp,~tiariwt;.ejinqlii~hedunle$~thi~ is done. w~i1eyouare under investigation ; or, in refuriitor n'qtcooductijlg'all investigation or proceeding. If'Ptjyileg.e~ ate t()be reported as voluntarily relinquished you will be notified and..r:~~eixe\l~!ipl'of*lterep~:rt.to,:b~ filed wit~.tj:te. NationatPra;ctitil).jt.er Datailank.,>~,~~,~{, fos.~l, '. " f.),'~;~f:;j<;~;,,:.:"..:~.:,')}:,,":' '..~ractitionetls Sigl1atutc..,~ A$i M':~Wje~~~~i;f;bysj~ian/QILiajSonlJ)epa.riineot Cbairfl\fedi~al:llirecto;l. Service 'Center..AdmJitistrator, we have.,r~vie~e;(ft.q; ~W";!;IJe~'I\Jl~'$;lev~1 Of,ewerj~nc.e,pas~perforJllllnc~aRdquality indiclltors (if renewing privileges) as r _'"relafed t&,r '_< st~d'p.r~vjleges anda.gree 'that the above named AUJ>'s.quaUf'jcatioos'are appropriate. Since thedate of'fhe'fast appqiot;pi Q~~/~e'b~ ef~;yjew.ed appj.icableill.f9rmation fromthcf{)llowiitg s~urces ofqualityanduti\iilation data:. <: J~"1k-_~,~>..:::':'; ~; o o """ Annual Evaluation Studl'mtEvaluation AnnualReview by Dept. Chait orsca,-.,'. W~.'filt~;~s.foU~wSJ:<. ',~~c~~~ictt>le're~iti~ ": ',' " ",c_,_,', ",' _\_,.. ",..., " _"..,~... -,':.' ~jth;c~c~irl';:"ij:hdalio.n,of :re3~p6il"):tment wuh linic~u,prjvilege$,.. -.' c.: '" _.. ---",..., '" ;",".. -, -.' " -- - _ -.. ",..., ,- _ as requested. - Robert Boyle. M.D. Printed Name.John Kattwinkel. M.D. Prinb~dName C,,:_:. ~1.Z:J1CJ. David Kaufman. M.D.. Printed NalTle ::I)~t~.' (l~j IJ Karen Fairchild,M.D. Pri ntedname 'Dafe 7/Jbj)j 'Oate Date. Lorna Fa,cteau. DNS.RN. Chief of Nursing./ Printed Name Chair/RPC Director Signature (for HSFemployees) Printed Name. revised 3/1/2005
14 AHP Clinical Privileges Update Form _~ Y)_(_d_-=O=-. _U-_C--.::fL~~ Department Of_-+jJ--.::-"'-'/"--C=-..::.~ _ ~ have reviewed the privilege reviously granted (copy attached) to me and request the following changes: ~~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. Date As the Supervising Physician/QI LiaisonJDepartment Chair/ 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: o Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Record Review o Continuing Education Conferences D Physical & Mental Health related to Job Performance D Risk Management Events/Quality Management Reports for claims D Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Ofuer ~ _ We find as follows: '&t> Acceptable review with recommendation of reappointment with clinical privileges as requested. I D Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges e, -i;;r~;ested, but subl 0 a r:j in --\ m::. L- ~~~f 0)( e.v;s;n y ;c;an S;gatu," t\~i\d< LDatG ~ Date ~-,~ I :J.g I 08 Date Printed ~~.~ Printed Name Name Date Chair/RPC Director Signature (for HSFemployees) Printed Name revised 3/1/2005
15 ~lek.o AHP Clinical Privileges Update For.m Department of_-,! ~:.-...!/~c»'~~-=.-j== ~-l have reviewed the privileges pr iously granted (copy attached) to me and request the following changes: 3ew 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, As the Supervising Physician!QI LiaisonlDepartment Chair/ 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: ~ ~/ Record Review Annual Evaluation [i2f... Continuing Education Conferences 0 Student Evaluation ~Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA G1'jRisk Management Events/Quality Management Reports for claims [Q' Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: f Acceptable review with recommendation of reappointment with clinical privileges as requested. o ~()\c.e-;t Printed Name 'b\9y_\ e, T jo~j.j tai-(w,1-/ ((t:.-( Printed me, D'itE! ---1 {\2\ '0", Date PrintE!d NcIr1e l e.ll l1jc~ Printed Name A]J Printed Name ~ ' ''\,ivu~ ~ I {CV'l.!V\. ~ reoi~ed 3/1;'2995
16 ,. -r=>: Privilege List for: Neonatal Nurse Practitioner 27-Jun-05 Name: 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. ~~edical Iedical ~rocedure. rocedure Arterial CPR cannulation Intubation & Mechanical Ventilation Circumcision Lumbar Peritoneal ECMO Puncture dialysis Premature Disorders Dx & Tx Premie Growth & Development Neonatal Intensive Die Dx & Tx Birth Defects Eval Intubation & Mechanical Ventilation Neonate Sepsis History and Physical Dx, Assessment & Mgt Telephone Triage/Consultation Hospital Rounds Patient Education Admissions (with MD collaboration) Order Order Order Order Order Order Order - Labs - ECG - Echocardiogram -EEG - Radiographs Consults Medications NICU - Pre/Post Op Mgt NICU - Sedation & Pain Control Ventilator Weaning Mgt Nutritional Exchange Status. Eval & Mgt Transfusion Peripheral Central Venous Line Placement Mickey. Gastrostomy Neonatal Resuscitation Pacemaker Insertion- Assist PEG Placement- Assist Buttons - Changing PH Probe > Insertion & Verification of Placement Sedation TPN Ordering Umbilical Catheter - Arterial or Venous Neonatal Ped Adol Adult Geriatric r- C L N\(\ r./ C- c, c, r c. C c C c c, o, c. C (' r (" r: c, L- (... c, (' C- L c c, ~. L c. ~\{; >.1/.(\ ~l(\ r C C Page 1 of 2
17 Cardiac Care - Pre & Post Op Cardiovascular Dif Dx & Tx, Congenital Heart Disease.vledical Hyperbilirubinemia Immunization Prenatal Counseling Chest Tubes - Clamp and/or Remove Newborn screening Chest Tubes - Insertion & Mgt Authorized to Prescribe Evaluate - ECG Evaluate - Echocardiogram Evaluate - EEG Evaluate - Labs Evaluate - Radiographs OTHER PRIVILEGES Neonatal, Ped Adol Adult Geriatric C C c. c. c. c. C. G C_ r. c. c c. c, V 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 ~( 2-C[ ( -s: OA-IJ K.A-- Name Printed DATE DATE q, I~\ ID ~ DATE -j ~b 16(; DATE uc<-k g- (w (Or- <).(2.0)- ql4l~ Dept Chair 'or. Svc enter Administrator Name Printed v.p~ \ Page 2 of 2
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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 informationCLINICAL PRIVILEGES- PEDIATRIC SEDATION SERVICE APP
Name: Page 1 Initial Appointment Reappointment Department Specialty Area All new applicants must meet the following requirements as approved by the governing body effective: 8/7/2013 Applicant: Check off
More informationQuality Indicators in Neonatal Medicine
Quality Indicators in Neonatal Medicine Potential collaborative research projects Imad MELKI M.D. NCPNN Quality Indicators: 1- An agreed-upon process or outcome measure that is used to determine the level
More informationCriteria for Registration in Paediatric Neonatology
Criteria for Registration in Paediatric Neonatology Any doctor can request to be registered in Paediatric Neonatology if he/she fulfils ALL the following requirements: 1. A recognised basic medical degree
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 informationCERTIFICATE OF COMPLETION OF PAEDIATRIC LEVEL 1 COMPETENCY V1.0
Applicants applying for ST4 posts in paediatrics may use this certificate to successful, satisfactory completion of Level 1 paediatric competences, as defined in the RCPCH Level 1 Paediatrics and Child
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 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 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 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 informationINTERNAL 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
More informationNeonatal Intensive Care University of Michigan Mott/Holden NICU
EDUCATIONAL GOALS: 1. PEM Fellows will become familiar with basic principles of neonatal emergencies including evaluation and management of the newly born premature infant. Competencies: MK, PC 2. PEM
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 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 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 informationSARASOTA MEMORIAL HOSPITAL STANDARDS OF CARE STANDARDS OF PRACTICE NEONATAL TRANSPORT TEAM
UNIT: SARASOTA MEMORIAL HOSPITAL STANDARDS OF CARE STANDARDS OF PRACTICE NEONATAL TRANSPORT TEAM STANDARD #: EFFECTIVE DATE: REVISED DATE: STANDARD TYPE: 11/93 3/18 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS
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 informationBASIC STANDARDS FOR SUBSPECIALTY FELLOWSHIP TRAINING IN NEONATAL MEDICINE
BASIC STANDARDS FOR SUBSPECIALTY FELLOWSHIP TRAINING IN NEONATAL MEDICINE American Osteopathic Association and American College of Osteopathic Pediatricians TABLE OF CONTENTS 1 Article I. Introduction...
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 informationPEDIATRIC ALOC Guidelines. ALOC Guidelines ALOC
PEDIATRIC Guidelines Guidelines The Alternate Level of Care () Guidelines are intended to assist the reviewer in identifying the next safest and appropriate level of care options. They allow the reviewer
More informationADVANCE DIRECTIVE FOR HEALTH CARE
ADVANCE DIRECTIVE FOR HEALTH CARE This document includes a list of definitions and the two types of Advance Directives (together called a Combined Directive). Some people choose to fill out only one portion.
More informationObjectives of Training in Neonatal-Perinatal Medicine
Objectives of Training in Neonatal-Perinatal Medicine 2007 This document applies to those who begin training on or after July 1 st, 2007. (Please see also the Policies and Procedures. ) DEFINITION Neonatal-Perinatal
More informationPediatric 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
More informationJOB DESCRIPTION Safe, compassionate, effective care provided to our communities with a transparent, open approach.
JOB DESCRIPTION Safe, compassionate, effective care provided to our communities with a transparent, open approach. JOB TITLE: GRADE: BASE: MANAGED BY: Advanced Neonatal Nurse Practitioner Band 8a Homerton
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 informationProvincial Nursing Competencies List of e-learning Modules. Updated: September 25, 2015
Provincial Nursing Competencies List of e-learning Modules Updated: September 25, 2015 Once you sign in on the home page, you will see the following search screen on the right hand side of the page: Search:
More informationNeonatal-perinatal medicine
Practice area 153 Clinical PRIVILEGE WHITE PAPER Background Neonatal-perinatal medicine Neonatal-perinatal medicine is the subspecialty of pediatrics that involves the diagnosis and treatment of high-risk
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 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 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 informationNASI Per Diem Malpractice
Dear Nurse Anesthetist, We appreciate your interest in NASI s Per Diem Malpractice Insurance. This service is for those providers who need a supplemental policy for working an assignment outside of their
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 informationPrivileges 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
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 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 informationALOC Guidelines ALOC. PEDIATRIC ALOC Guidelines
PEDIATRIC Guidelines Guidelines The Alternate Level of Care () Guidelines are intended to assist the reviewer in identifying the next safest and appropriate level of care options. They allow the reviewer
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 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 informationThe 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.
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 informationSkills Assessment. Monthly Neonatologist evaluation of the fellow s performance
Patient Care Interviews patients The Y1 will be able to verbally obtain an accurate history on new NICU: Observation of Neonatologist evaluating a Goal: Practice patient care accurately and effectively
More informationNEPHROLOGY 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
More informationPediatric ICU Rotation
Pediatric Anesthesia Fellowship Program Department of Anesthesiology 800 Washington Street, Box 298 Boston, MA 02111 Tel: 617 636 6044 Fax: 617 636 8384 Pediatric ICU Rotation ROTATION DIRECTOR: RASHED
More informationCare Extender Internship Program. Ronald Reagan-UCLA Medical Center Department Descriptions
Ronald Reagan-UCLA Medical Center Department Descriptions 5ICU (PICU) 2 nd rotation and up Child Life training & department shifts are mandatory; training dates will always be indicated on the preferences
More informationDuring 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
More informationPediatric Intensive Care Unit (PICU) Elective PL-1 Residents
PL-1 Residents Interns 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
More informationProgram Catalogue For the RCFD Paramedic Program. Rapid City Fire Department 10 Main Street Rapid City, SD 57701
Program Catalogue For the RCFD Paramedic Program Rapid City Fire Department 10 Main Street Rapid City, SD 57701 CoAEMSP Committee on Accreditation of Educational Programs for the Emergency Medical Services
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 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 informationB. 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
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 informationNeonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy
In the event of conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include,
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 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 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 informationTheValues History: A Worksheet for Advance Directives Courtesy of Somerset Hospital s Ethics Committee
TheValues History: A Worksheet for Advance Directives Courtesy of Somerset Hospital s Ethics Committee Advance Directives Living Wills Power of Attorney The Values History: A Worksheet for Advanced Directives
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 informationA Family Guide to ECLS
Image Credits The cannula placement image on page 3 is used with permission from Columbia University and www.coachsurgery.com. The ECLS images on pages 4 and 5 are used with permission from Maquet CardioHelp.
More informationFAMILY 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
More informationNEW YORK STATE DEPARTMENT OF HEALTH Medical Orders for Life Sustaining Treatment (MOLST) THE PATIENT KEEPS THE ORIGINAL MOLST FORM DURING TRAVEL TO DIFFERENT CARE SETTINGS. THE PHYSICIAN KEEPS A COPY.
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 informationNeonatal ICU Rotation
Pediatric Anesthesia Fellowship Program Department of Anesthesiology 800 Washington Street, Box 298 Boston, MA 02111 Tel: 617 636 6044 Fax: 617 636 8384 Neonatal ICU Rotation ROTATION DIRECTOR: SUNITA
More informationDepartment: Medical Management Utilization Policy #: UM24 Effective Date: 02/01/1996. Medi-Cal Yes X No MCAP Yes X No TPA Yes No X
Subject: HEALTH PLAN OF SAN JOAQUIN Neonatal Intensive Care Unit (NICU) Services Department: Medical Management Utilization Policy #: UM24 Effective Date: 02/01/1996 Committee/Approval Date: Review/Revision
More informationSubmit your bills as soon as possible. Please check to see that the correct date is on the top with the month in writing rather than numbers.
OHIP BILLING for ANESTHESIOLOGY (Updated November 2007) Getting started. Keeping on track Review the SOB (Schedule of Benefits) on line at either the OMA website or the MOHLTC website at www.health.gov.on.ca/english/providers/providers_mn.html#ohip.
More informationNICU Resident Manual
McMaster Children s Hospital NICU Dr. Connie Williams, Neonatologist, ERP for Neonatology Office: 4F1A willico@mcmaster.ca Ms. Jessica Okis, Assistant Office: 4F okisj@mcmaster.ca Welcome to the NICU!
More informationSTANDARD NURSING AGENCY
STANDARD NURSING AGENCY 5 Forum House Empire Way Wembley Middlesex HA9 0AB Tel: 020 8900 9519 Fax: 020 8900 9587 recruitment@standardnursing.com REGISTRATION FORM PERSONAL DETAILS Surname Title First Name(s)
More informationPreparing and Registering S.T.A.B.L.E. Support Instructors
Preparing and Registering S.T.A.B.L.E. Support Instructors If a person is unable to attend an official National or Private Instructor course, but they wish to co-teach a S.T.A.B.L.E. Learner course with
More informationPerinatal Designation Matrix 3/21/07
Codes: N = Neonatal Criteria M= Maternal Criteria P= Perinatal Criteria (both N & P) Perinatal Designation Matrix 3/21/07 Service/ 1. (N) Minimum NICU bed capacity Minimum of 10 NICU beds. Minimum of 15
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 informationHyperbaric 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 information2016 Annual Associate Safety Modules Section 7 Safe Medical Devices Act (SMDA)
2016 Annual Associate Safety Modules Section 7 Safe Medical Devices Act (SMDA) Reporting Defective Medical Devices WHAT IS S.M.D.A The Safe Medical Devices Act (SMDA) is a federal act designed to assure
More informationRegions Hospital Delineation of Privileges Certified Registered Nurse Anesthetist
Regions Hospital Delineation of Privileges Certified Registered Nurse Anesthetist Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting.
More informationFamily 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,
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 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 informationICU Nurse, 10 years experience. Major NHS hospital north of London
NAME AND CONTACT INFO WITHHELD CONTACT PASSPORT USA FOR FURTHER DETAILS. 855.531.8555 ICU Nurse, 10 years experience. Major NHS hospital north of London DATE OF BIRTH: March 1, 1977 NATIONALITY: Filipino.
More informationDirectorate of Women & Children s Health Services JOB DESCRIPTION
Directorate of Women & Children s Health Services JOB DESCRIPTION JOB TITLE: Staff Nurse - NICU GRADE: Band 5 DIRECTORATE: RESPONSIBLE TO: ACCOUNTABLE TO: Women & Children s Health Ward Manager Assistant
More information