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Clementine Hawkins
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7 Clinical Privileges Update Form Sachin Mehta Department of Anesthesiology '"~'-''''' ~.~T- ~'ystem l.rnversty. ".".'VHGNJA 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:'" ,.._.... _...,... " _...._.,,-.--._..._... r~p~ivli~ges' ~ot 'r~ne~~d'~r~notr;;po~:ted~~s 'ii~ingvoii;;;t~rlly~ei'h;q~lshed' ;~niess this is done wiiiieyou l~e u~deriiiv~stigaiion"~ or, n return for not conducting an nvestigation or proceeding. fprlvllege8.~re to be reported a8 voluntarily relinquished you will be liotlfied and,'ecelve a copy of the report to be filed with the Natlonall\lac 'oner Databank..._...-._ As the Division HeadlQ 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 rehled to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the foowing!s01~rces of quality and utilization data: ; " i We ~ows; t. \.,'.. ~ Acceptable review with recommendation of reappointment to the clinical staff with clinlcal\p~ivlleges as requested' D Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject t~ a review n months. D Should have clinical privileges granted but restricted as follows:--.l it? ~/; _..."..._---_.._----- t/r/(z- ---H~---''''-- >~..., "..-,---- Revised 31"~006

8 Clinical Privileges Update Form.Sachin Mehta Department of Anesthesiology 1have 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: * -----~ "'~,.,.~_..,..~,_,", ',,'.,... ~."'~,~._"_._.',~. '~,, '''..."'.'.~.",. " ~ w. Y._ ~, _,'. '~,~,.. ~hn H_~..= h~-~o'"" =w"-n,r ' '",, u,,, ~,= ""...~.~..."",","" '.... 'W. ".~,~.",._.,.-,~."N._h.'.,".-.-.~~., ~~.. _-, _,". ~,. >, ~m~m,~. _ :*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 vlll be notified and receive a copy of the report to be filed with the National Practitioner Databank. Jt7 CLNloiAN SGNATURE ~ As the Division Head/Q Liaison and Department ChairlMedical 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 of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We fi~~y follows: 10 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested oj 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. Should have clinical privileges granted but restricted ~ ws: _ 3/j/~. ~, ----Af ~------~-- "ATE Revised 3/112006

9 Clinical Privileges Update Form Sachin Mehta Department of Anesthesiology U~VEl~STY ~ o/v RGNA lh.ealth SYSTEM 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:* '~'p;ii~ii;~;~~;;;;;:';;~,~-;;;;-~;:,:' ~;;t~:;~';;;~;; '--"--"---'"-''''... '--'"''--~",'""",""''''''''-,-",,,,-...,,,,,,,,,-,,,--,-.,-,,,,,,-,,,-",-"-"".,.,_...,.",. -,..,-'" '*1 not renewed are not reported as being voluntarily relinqulshed unless this is done while you are under investigation;.,01', 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 P' itioner Databank. CL~ SGNATURE As the Division Head/Q Liaison and Department Chair/Medical Director, we have reviewed tbe 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 of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We r~s follows:. l{j Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D D 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. Should have clinical privileges granted but restricted as fol ows: _ 'flirt00 Revised 3/1/Z006

10 Clinical Privileges Update Form Sachin Mehta Department of Anesthesiology lj~'versry..()lv 'R G N A ".D")'~..." T 1... = lj.f..alt SYsTEM J 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:* :*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 Pr itloner Databank. As the Division Head/Q Liaison and Department ChairlMedical 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 of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We f~ follows: l{j Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D D 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, Should have clinical privileges granted but restricted as foljows: _ /~ ul/(./100 t.'~!'-"~,, />".",,/ 711 (t // /p;/.:>;/ --~~----~~ Revised J/l006

11 Privilege List for Clinical Staff 08-Sep-OO DEPARTMENT OF ANESTHESOLOGY Name: Date: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSGNED TO PRACTCE; EMERGENCY PRVLE,GES 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. ACCORDNG TO CATEGORY, ENTER A.,B, OR C N THE REQUESTED COLUMN NEXT TO THE LSTED PRVLEGE: A The applicant will Hot undertake patient ruanagement/procedure except in emergency. B The applicant will occasionally manage patients or assist n muuagement/perform the procedure/assist in the performance, Consultation will be sought in the event of unticipated or actual difflculties. C The applicant. will ndependently manage patients/perform the procedure, The applicant would be expected to request consultation only occasionally. ACCORDNG TO TY)'E, ENTER 1,2, OR 3 N THE COLUMNS N THE EXPERENCE COLUMN: Completed Formal Training Pro grant. 2 Limited Experience. without fonnal truining. 3 Extensive Experience. without formal training. UV A Outpatient Surgery Center Privileges ~es o No Medical Anesthesia/Pain Privilege: Category Requested Hemodyn antic Support Consults Pain Con sultation C Pain Diff Dx&Tx c. Pain Man agement - acute r: Pain Man agement - chronic C Periop- Unrestricted med assess & mgt C / Postopera Preoperat Critical Care General r'rocedure tive Assess C ive Assess r: ) Critical Care - Neurology CU - Un restricted Care e Neonate intubation & mech vent e t PC intub ation & mech vent p f PC sedati on, pain control /{ Pharmacologic Airway Control Mgt 1 c!j c Type Experienc

12 ,' Privilege List for Clinical Staff 08-Sep-OO DEPARTMENT OF ANESTHESOLOGY Name: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHEHE YOU AH.EREGULARLY ASSGNED TO PRACTCE; EMERGENCY PRVLEGES SHOULD BE MARKED WHERE YOU ARE THE DESGNATED PERSON TO COVER ANAREA N WHCH YOU DO NOT REGULARLY PnACTCE. AREAS N WHCH YOU DO NOT REGULARLY PRACTCE SHOULD BE LEFT BLANK. Date: ACCORDNG TO CATEGORY, ENTER A, B, OR C N THE REQUESTED COLUMN NEXT TO THE LSTED PRVLEGE: A The applicant will not undertake patient manugcrnent/procedure except in emergency. B The applicant will occasionally manage patients or assist in munagement/perform the procedure/assist in the performance. Consultation will be sought in the event of anticiputed or actual ditfleulties, C The applicant will independently manage patients/perform the procedure, Tle applicant would be expected to request consultation only occasionally. ACCORDNG TO TYPE, ENTER 1,2, OR 3 N THE COLUMNS N THE EXPERENCE COLUMN: Completed Format Trnuung Program, 2 Limited Experience - without formal training. 3 Extensive Experience - without ormal training. UV A Outpatient Surgery Center Privileges ~es o No Medical AnesthesialPain Privilege: Category Requested Hemodyn amic Support Consults Pain Con sultation Pain Diff Dx&Tx Pain Man agernent - acute Pain Man agement - chronic C C r C Periop- Unrestricted med assess & mgt C Postopera Preoperati Critical Care General Critical C lcu - Un tive Assess C / ve Assess r J are - Neurology, restricted Care GJ Neonate intubation & rnech vent e f Type Experienc, PC intub ation & mech vent f) PC sedan on, pain control P-,~ Pharmaco_lo-.!g;:..i..:.C..:.M..:.gt=:.:... -L_.==C=- -t- ---' rocedurc c Airway Control 1

13 .r--- Category Type ~ Privilege: Requested Experienc Manual assisted ventilation (BVM) C j Tracheostomy - percutaneous e ~ Anesthesia/Pain AirwayM gt - LMA insert & intubation, unrestricted 1 Airway Mgt - trach intub., flex. fiberoptic assist C Airway Mgt - tracheal intub., anesthetized pt C AirwayM AirwayM gt -Laryngeal mask airway insert, restrict C Anesthes ia.. local, epidural C. Anesthes ia.. local, field block C Anesthes ia.. local, injection C Anesthes Anesthes Anesthes Anesthesi a Conscious C. Anesthesi Anesthesi Anesthesi Anethesia Anethesia Echocard Neuroniu Neuromu PainMgt PainMgt Critical Care i.mergency Mechanical CPR Endoscopic gt - tracheal intubation, awake C ia -ocal, major nerve block C ia - local, spinal C ia Administration C a 'ntercostal Nerve Block r: / a Local c, a, local - minor nerve block c, - general, admin, for endotrach. intubat c.. - general, administration- unrestricted c... / iography - intraoperative transesophageal e /L sc. Blocking Agent - admin intubated pts C scular Blocking Agent - admin, unrestricted C. / - epidural, single shot or continuous c - intrathecal/epid.caths, pump implant c.. c, - intrathecal/epidural caths, long term - nerve blocks c, / - Neurolytic nerve blocks 1-\ 1- - Opioid/local anesth, unrestricted C / - PCA (pt. controlled anesthesia) C. / - Radiofrequence nerve ablation f 'L - spinal, single shot or continuous C. / - conscious - intubated pts C - conscious, non-intubated pts C. - deep, intubated pts. C - deep, non-intubated pts. C - V, unrestricted C ventilation c G 2

14 Category Type ) Privilege: Requested Experienc Manual assisted ventilation (BVM) C Tracheostomy - percutaneous e ~t Anesthesia/Pain AirwayM AirwayM AirwayM AirwayM Airway M Anesthes Anesthes Anesthes ia - local, injection C Anesthes ia - local, major nerve block C Anesthes ia - local, spinal C. Anesthes ia Administration C Anesthes ia Conscious C. Anesthes Anesthes ia Local c.. Anesthes ia, local - minor nerve block c, / Anethesi a - general, admin, for endotrach. intubat c.. Anethesi a - general, administration- Echocard iography - intraoperative unrestricted transesophageal <, B / /L Neuromu sc. Blocking Agent - adrnin intubated pts C Neurorm iscnlar Blocking Agent - admin, unrestricted C. - epidural, single shot or continuous C PainMgt - intrathecal/epid.caths, pump implant c.. c.. - intrathecal/epidural caths, long term PainMgt Critical Care i.mergency Mechanical CPR Endoscopic gt - LMA insert & intubation, unrestricted c 1 gt - trach intub., flex. fiberoptic assist C gt - tracheal intub., anesthetized pt C gt - tracheal intubation, awake C gt -Laryngeal mask airway insert, restrict <:: ia - local, epidural C ia - local, field block C iantercostal Nerve Block r: - nerve blocks c... / - Neurolytic nerve blocks q 1- - Opioid/local anesth, unrestricted C - PCA (pt. controlled anesthesia) C - Radiofrequence nerve ablation A 1- - spinal, single shot or continuous C. / - conscious - intubated pts C / - conscious, non-intubated pts c / - deep, intubated pts. C. - deep, non-intubated pts. C - V, unrestricted C ventilation 2 c G

15 Bronchoscopy Privilege: Category Type' Requested Experienc c. ~~ ~ ~ ~ Vascular Central Venous Catheter - C. nvasive Monitor. - arterial catheters nvasive Monitor. - central venous catheter ~ C J n vasive Monitor. - vascular, unrestricted c /J J / Lf'll,'O //.wt jf/~ DAT E,// CLNCAN SGNATURE / t/ As the Division Head/Qf Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level of experience and training as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Therefore, we reco mend the appintment to the Clinical Staff with the clinical privileges as requested. c.~ 3

16 Vascular Bronchoscopy Privilege: Category Requested c Type ~ Experienc.~ ~~ ~ ~ Central Venous Catheter nvasive Monitor. nvasive Monitor. - arterial catheters - central venous catheter nvasive Monitor. - vascular, urrrestricted J c ) t//1lf!~7 /11:;t, 'f~ '/ CLNCAN SGNATURE {,/ As the Division Head/Q Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level of experience and training as related to requested prrvileges and agree that the above named clinician's qualifications arc appropriate. Therefore, we reco mend the appintmcnt to the Clinical Staff with the clinical privileges as requested, " c: C. C J _----"'(1 ~~l7 'Lf DVSON HEAD! LASON SGNATURE //-=<7 '2.1..,PEPARTMENT CHAR SG TURE 3

UNMH Anesthesiology Clinical Privileges

UNMH 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