AHP Clinical Privileges Update Form

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Dina Cooper
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2 AHP Clinical Privileges Update Form "'--, Dyan Aretakis Department of OB/GYN 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):.j 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. f 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. Practitioner's Signature As the Supervising Physician/Q 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 qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: 0' Record Review Z Annual Evaluation fzj.continuing Education Conferences o Student Evaluation!Z( PhysicalzsMental Health related to Job Performance o Annual Review by Dept. Chair or SCA jz( Risk Management Events/Quality Management Reports for claims,tj Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other...,..-.._~ ' We find as follows: ;Acceptable review with recommendation of reappointment with clinical privileges as requested..3.{ ~",qu.sted. butsur)' toa revlew ln months.. ~ o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges ~ o ~ /1A. {\.,1cttt-l!O Nancy A. McLaren. M.D... Primary superv~~ng Physici_~nSignature 1,. t) -.,' Katherine W. Kent. M.D. Oat Alternate Su~erv i Physician Signature Alternate Supervising Physician Signature 16/.5-j;o Shelia Smith. Associate Chief Chair/RPC Director Signature (for HSF employees) revised3/1/2005

3 AHP Clinical Privileges Update Form Dyan Aretakis, NP Department of Teen HealthCenter -,;have reviewed the privileges previously grauted (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. f 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. Practitioner's Signature As the Supervising PhysicianlQ Liaison/Department 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: E1 Record Review ~ Continuing Education Conferences!Xi Physical & Mental Health related to Job Performance ~ Risk Management Events/Quality Management Reports for claims ~ Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other N oo 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. 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. qlr~/d<? \~ (V\ M~ MO Dale Pri at#iupervising Physician Signature Nancy McLaren, MD ~ t K&rine Kent. MD Alternate Supervising Physlcian Signature,- ql" {_O'&_ Terry Lucas Chair/RPC Director Signature (for t-sfemployees) revised 3/1/2005

4 / : AHP Clinical Privileges Update Form ~h ~ Department of rfejj) -W1-6 C@/ut,..--"_ have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category leveand type of experience): f!'\\. plqw\tsv1 Vvt ~Vv'h 1.:"" ( <;. "J,,<:.. i,'\-w-<'".-fv 'N Cy,"?0vy-vi- VV\ ~A_hv,-- "" - c Current Privileges not to be renewed: * ~"A * 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, f privileges are to be reported as voluntarily relinquisbed you will be notified and receive a copy of the report to be tiled with the National Practitioner Databank. Practitioner's Signature As the Supervising Physician/Q 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: if Record Review ~ Annual Evaluation er Continuing Education Conferences 0 Student Evaluation l6'physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA 0" Risk Management Events/Quality Management Reports for claims f Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ 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, 7te (11JOb Printed KC\t-h 't l:::..ev\.t' / 7 iqnatura ame Alternate Supervising Physician Signature.>: _~,1;),,/ 1/)../Db Alternate Sup~ising Physician Signature '~Ozl c.uj }v(5j, 12..;:;. CliT1iCalie Svcs Adm{nistrator (for Me employees) Tz, te..f2l( l.o.ca-"s Chair/RPC Director Signature (for HSF employees) revised 3/1/2005

5 ~r.a~s,. AHP Clinical Privileges Update Form Department of 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. f 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. u [t 0 \ 0"( Pract tioner' gnature As the Supervising Physician/Q LiaisonlDepartment Chairf 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 ~pointment, we have reviewed applicable information from the following sources of,quality and utilization data: Record Review Annual Evaluation 0'"~ontinuing Education Conferences 0 Student Evaluation [?' Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA ~ /Risk Management Events/Quality Management Reports for claims &' Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other _ We find as follows: ~cceptable 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. N((f)0\ M. ~~eq ~. Kw!heN/~ print.dnilm~ '/ L L/At7~ Alternate Supervising Physician Signature J1!}1&5OZTByLo/2

6 AHP Clinical Privileges Update Form -rr-.;'o~tlh ~ Department of ~ an [~ [16 {[fj;., 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): P~~}f+ec~ CU'rent Privileges not to be renewed: * N~~~ _ * 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. f 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, i AHP Signature Supervising As the Physician/Q Liaison/ Department Chairl Director/ Service Center Administrator, we have reviewed the above-named HCP's level of experience, past performance and quality indicators (if renewing privileges) as '~'elated to requested privileges and agree that the above named HCP's qualifications are appropriate. Since the date of the.ast appointment, we have reviewed applicable information from the following sources of quality and utilization data: Record Review Hep's Health and Mental Status Continuing Education Conferences Sentinel Events/Risk Management Reports 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. ---!...;,.i \ ~ 0L \Ol6l\O'2..- '0\ 3d_ol- Oat _ Collabor' ysician gnature ~ffi N\(1-<,==-1lv) Collaborating Physician Signature 11~1/-6 c CO"'bO~ Revised 03/21/200

7 'b'(ah A r-ej-a..l4s HCP Clinical Privileges Update Form Department of 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: * --tf\~. *Privilege3 not renewed are not reported as being voluntarily relinquished unless this is done while you are under lnvestigatlon; or, n return for not conducting an nvestigation or proceeding. f privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be flled with the National Practitioner Databank. HCP Signature As the Supervising Pbysician/Q Liaison! Department ChairfMedica 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 and utilization data:. We find asjpuows: Record Review HCP's Health and Mental Status Continuing Education Conferences Sentinel Events/Risk Management Reports g/' 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 subjectto a review in months. 4Jsk\.D'-at-e ~~L Service 51nte: Adm;?;~ if!("""!vi A/~.J?5l- 0 J-v) Collaborating Physicia iqtlk. Lf(c5/0( LYu~ f)'7 rylc(ov-.- NCJ Collabora tng PhYSCian Signature o o Collaborating Physician Signature R"",sed

8 .-l?rivilege List for Family NP Name: ~J-Feb-99 : PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSGNED TO PRACTCE; EMERGENCY PRVLEGES SHOULD BE MARKED WHERE YOU ARE THE DESGNATED PERSON TO COVER ANAREA N 'WHCH YOU DO NOT REGULARLY PRACTCE. AREAS N WHCH YOU DO NOT REGULARLY PRACTCE SHOULD BE LEFT BLANK. Are you requesting privileges to prescribe (you must have a current Authorization to Prescribe to d ACCORDNG TO CATEGORY, ENTER A. B, OR C N THE COLUMNS NEXT TO THE LSTED PRVLEGE: 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. Privilege: Peds Adol Adult ~riatric General Admissions (with 1'vD collaboration) General Authorized to Prescribe,r> General ' Dx; Assessment & Mgt C,- General Evaluate - ECG General Evaluate - Echocardiograrn General Evaluate - EEG General Evaluate - Holter Monitoring General Evaluate - Labs l General Evaluate - Radiographs General Evaluate - Urodynamic Studies General History and Physical c General Hospital Rounds General Order -ECG General General General Order - Echocardiogram Order -EEG Order - Holter Monitoring General Order - Labs C General Order - Radiographs r: General Order - Urodynamic Studies General Order Consults C General Order Medications C General Patient Education C ;:Jeneral Telephone Triage/Consultation r Adjustment Problems (" - -- Aliergyllmmun DifDx & Tx r Arthritis Attention Deficit Disabilities Birth Defects Eval Cardiac Rehab Cardiovascular Dif Dx & Tx Cerebral Fai;,) i 1

9 Privilege: Peds Adol Adult Gerla~ric Cholecystitis Medica1 Cirrhosis Medica1 CNS nfections Cognitive Rehab Congenital Heart Disease Contraceptive Counseling C Medica1 Croup, epiglottitis Medica1 CVARehab Medica1 Cystic fibrosis Dennatologic Diseases - Dx & Tx r Diabetes Mellitus Medica1 Dialysis Mgt Drug Reaction & Overdose Medica1 Electrolyte & Water Balance -, -: EndocrinelMetabolic Dif Dx & Tx. Fractures & Dislocations General Med Dif Dx & Tx C General Peds Dif Dx & Tx C Medica1 Geriatric DifDx & Tx edica1 G Disease Dif Dx & Tx C Gouty Arthritis Medica1 Gynecologic Routine DifDx Head & Spinal Cord njury & Tx C "M Health Maintenance & Disease Prevention C Heme/One DifDx & Tx Hepatic Diseases DifDx inv, ADS & Tx Hyperbilirubinemia CP Adjust Treatment Protocols nununization C. Medica1 nununodeficiency mpotence - Evaluation & Mgt "'"'> nfectious Disease Dif Dx s. 1x ",- Medica1 nfertility nitial Eval & Mgt Malabsorption M edical Neurodegenerative Disorders Medieal Neurological DifDx & Tx Newborn DifDx & Tx,.-".~M edical Newborn screening M edical Health Maintenance C edical Nutritional Status - Eval & Mgt e OB - High Risk Prenatal & Postpart Eval & Mgt 2

10 Privilege: OB - ntermed. Risk Prenatal & Postpart Eval & Mgt A OB - Routine Prenatal & Postpart Eval & Mgt {" Osteoarthritis Peds Adol Adult Geriatric Pain Management r Pancreatitis Ped Behavioral Problems Ped Learning & language disabilities Ped Mental retardation Pediatric Emotional Disorders (J., Pituitary Conditions Pre & Post Op Cardiac Care Premature Disorders Dx & Tx Premie Growth & Development Prenatal Counseling C Psychophysiologic DifDx & Tx A Pulmonary Dif Dx & Tx Renal Dif Dx & Tx Rheumatic Fever - Acute Rheumatic Heart Disease Rheumatoid Arthritis RheumatologicNasc DifDx &Tx Serum Sickness Sexual Counseling C. Spinal Shock - Mgt Thrombophlebitis Urologic Disease - Dif Dx & Tx c:.. Urticaria P Ventilator Weaning Mgt Adjust Cardiac Assist Devices Adjust Pacemaker Settings Allergen mmunotherapy Ambulatory Halux 02 Saturation Anesthesia Local r Anesthesia Regional Proceoure ~ " Anoscopy Aneriai Blood Gas Arthrocentesis Audiometry Biopsy - Endometrial Biopsy - Vulvar BiopsylRemoval- Bone Marrow.. Skin Lesion Aspiration, 3

11 Privilege: Peds Adol Adult ~riatric Breath Hydrogen Test Camino Bolt Removal Cardiac Arrest - Assist Cerumen mpaction Removal Chemotherapy - PO!V!ntrathecal 1 Chest Tubes - Clamp and/or Remove Circumcision Colposcopy - Cervical BiopsylECC Condyloma Tx's C Conscious Sedation CPR ti Cryotherapy r Diaphragm Fitting r Doppler Monitoring of Fetus r: EMG EMG Biofeedback Endotracheal ntubation. Epicardial Pacing Wire Removal Fetal Monitoring C-~ Foreign Body Removal- External auditory Foreign Body Removal - Nasal 1 Foreign Body Removal- Subcutaneous Foreign Body Removal - Subungual Foreign Body Removal - Vagina r Hansel Smear - Nasal Secretions Histamine Provocation ncisionfdrainage of Abscesses ntermittent Catheterization Tx C ntracardiac Catheter Removal 1 ntradermal Skin Testing e TJD nsertion & Removal Lab Test - Blood Cultures - Draw C Lab Test - Cervical Cultures C Lab Test - Dipstick Urinalysis ( ~ Lab Test - Rectal Cultures -(' Lab Test - Soft Tissue Site Cultures r: Lab Test - Throat Cultures r: Lab Test - Urethral Cultures r Lab Test - Vaginal Cultures r: Lumbar Puncture -~- Microscope Eval - Amniotic Fluid Microscope Eval - Breast Discharge 4

12 Privilege: Peds Adol Adult ~riatrlc Microscope Eval - Post Coital Cervical Mucous, Microscope Eval - Urine L Microscope Eval - Vaginal Secretions C Nail Avulsion Norplant nsertion & Removal C Ornaya Reservoir. Ortho s - Clavicle Ortho s - Lower Extremities Ortho s - Nasal Ortho s - Ribs - Stable Chest Ortho s - Shoulder Dislocation Ortho s - Upper Extremities PAP Smear r Paracentesis Percutaneous Skin Testing Peripheral Central Venous Line Placement... Pessary nsertion & Removal Pulmonary Artery Catheter removal Pulmonary Function Testss ~ Sigmoidoscopy Skin Laceration Repair Slit Lamp Exam Spirometry Surgical Assist Surgical Drain Removal Thoracentesis Tonometry TPN Ordering Tracheostomy Tubes - Remove Transtracheal Aspiration Typanometry Ultrasound - Fetal Ltd - AF Ultrasound - Fetal Ltd - Dating 1st Trimester Ultrasound - Fetal Ltd - Fetal Cardiac Activity Ultrasound - Fetal Ltd - Fetal Presentation Urodynamic Studies - Percutaneous EMG Urodynarnic Studies - Rectal Tube nsertion Urodynamic Studies - Simple Office Cystometrics Urodynarnic Studies - Urodynamic Catheterization Ventricular Catheter Removal Wound Mgt - Debridement Wound Mgt - Assess for Functional ntegrity 5

13 Privilege: Peds Adol Adult Cri!riatric )rocedure Wound Mgt - Closure Wound Mgt - Dressing \ Wound Mgt - Electrocoagulation Wound Mgt - mmobilization Wound Mgt - Removal of Sutures/Staples L Wound Mgt - Wound preparation OTHER PRVll..EGES \V.. 3\q \~~ f DATE NURSE :l>racft NER SGNATURE As the Collaborating Physician and Department Chair Director, we have reviewed the abovenamed nurse practitioner's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named nurse practitioner's qualifications are appropriate. DATE..~ DATE ~ e it"\. i.h~. -( 0 v...., COLLABORATNG l)cio;.',-",j.,.. S~~ JLGO.. SCAN SGNATURE. cpojocy{>jj~ g)-v\a ~ ;.0. SGNATURE ~s~...:::..o_\ _--_ l:utc'...~ \).0<- -d < \~O\~_----- ~~ (V\ 1\'L~k.D / fy\ \... L~">-1' :-... CD( t ej:x'{,~ Pl~(c..v.-... jj~ Jd<a;;q,,?/yov'j Lu \jy.hjvw'"'\ r ~i v-4'-- 6

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