AHP Clinical Privileges Update Form Nicola Ratcliffe Department of Otolaryngology ~ lave reviewed the privileges previously granted (copy attached) to
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8 AHP Clinical Privileges Update Form Nicola Ratcliffe Department of Otolaryngology ~ lave reviewed the privileges previously granted (copy attached) to me and request the following changes: N'ewPrivileges tobe Added (please indicate category level and type ofexperience): Current PrivUegesnot.to be renewed:' * =Prtvileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under 'jnves~igatloit;!}t,in return for not conducting an.lnvestigatien or proceeding. Ifprivilegesare to lie reported asvoluntarjly relinquished you wlube notified and receive,a copy of the report to be filed witb t~enatioj)al Practitioner ataoank, ', As the Supervislng Physician/QI Liaison!DepartDie'ot. ClrairiMMical Direetor/ ServiceCel*rA~jnistrator, we have reviewed the <at,ove-natned AHP'slevel of experience, past performance and' quailtyindica,tors#fren~\vjng Ilrivil~.es)as.related to requested privileges and agree that tbe above named AHP'squalificationsare appropriate; Sill~ethe date of the last +-opotatment, we have reviewed applica.,bleinjormatioo(rom the following sources ofquahty3'n'd UHlizatlowi:I,ata: Medical Record, Review Q('ContinuingEducation Conferences '0 Physical &Mental: Health related to lohnrfonnance Risk Management pvents/qualitymanagementreports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2years) Other ~~ ~ ~~ ~ ~~~~ ~ ~~ ~~~ ~~ ~~ ~ Annual Evaluation o Stude~t~Valu.ati?Il.....< o AnntiaJRevlewbYDept.~hair or SeA' We find as follows: ~ceptable review with reeommehdationof reappointment with clinical privileges as requested.: o Concerns noted on review wilhcotreetiveaction plan in place withrecorrimendation 01reapP()Jnlmenfwith privileges as requested, but s/tject to a rev' in months. ~.~'~~~~-.--- i'marysupe JuckerGleasonj Printed'Name Ph.D. Alternate Supervising Physician Signature Printed Name Alternate SuperviSing PhYSician Signature Printed Name Alternate Supervising Physician Signature Printed Name Printed Name Paul Levine, M.D., Chair" Printed Name revised 3/1/2005
9 ,, QI,.~' AHP Clinical Privileges Update Form Nicola Ratcliffe Department of Otolaryngology-Audiology ave 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 asbeing 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, ~:)1--llo~.. ~~ Practitioner's Signatur~ As the Supervising Physician/QI LiaisonJDepartment Chair/Medical 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,,', ' rolntment, we have reviewed applicable information from the following sources of quality and utilization data: ( \. Medical Record Review Continuing Education Conferences Physical & Mental Health related to Job Performance o Risk Management Events/Quality Management Reports for claims Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Oth~ _ 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 su [ect to a revi in months. Tucker Gleason Printed Name Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name /-.._ Alternate Supervising Physician Signature Printed Name Printed Name ~Dte v10 ate Paul A. Levine, MD Printed Name revised 3/1/2005
10 ~'., AHP Clinical Privileges Update Form ~A..lo..It~{~C~O...L.l(&...~~tf1~u..:.lo",-fc)"..:Jd...~( m~e,---department of ~~=-::p-~~~------f.~=-..!~~-r have reviewed the privileges previously granted (copy attached) to me an requ 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. 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. '1!~1o/01;> ~ Practitioner's Signature As the Supervising Physician/QI LiaisonJDepartment Chair/Medical 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 /~'1ppointment, we have reviewed applicable information from the following sources of quality and utilization data: Medical Record Review Continuing Education Conferences Physical & Mental Health related to Job Performance o Risk Management Events/Quality Management Reports for claims Annual Evaluation Student Evaluation o Annual Review by Dept. Chair or SCA o 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 subj ct to a revie i months. ~'1frL'KtZGI t ftcl~j{ IA. D, Printed Name. Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name Printed Name?Avl{ A, UI),rJe I fi.i'j, Printed Name revised 3/1/2005
11 AHP Clinical Privileges Update Form ~11caf O--~Ccfcll~ Departmentof~~~~~--,--/k~d[o(o '~J I have reviewed the privileges previously granted (copy attached) to me a eque he following changes: J 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. 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 Prac itioner Databank. As the Supervising Physician/QI LiaisonlDepartment Chair/Medical 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 ~~intment, we have reviewed applicable information from the following sources of quality and utilization data: j2( Medical Record Review 0" Continuing Education Conferences!2( Physical & Mental Health related to Job Performance o Risk Management Events/Quality Management Reports for claims 0'" Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other We fin~ follows:. if 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. Pri -ItLdL# G~ Printed Name " Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name "---.. Alternate Supervising Physician Signature Printed Name Servic tr Administrator Vor Medi~1 Center employees), lpvv~j A.-tI}? Chairl r:director Signature (for HSFemployees) Printed Name tj?!~af!~ I
12 AHP Clinical Privileges Update Form Departmentof ~~ ~~~~~~~~~~-+ _ I have reviewed the privileges previously granted (copy attached) to me and rest 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. 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. iol!(,(q~ ka ~I AHP Signature Supervising As the Physician!QI Liaison! Department ChairlMedical Director! Service Center Administrator, we have iewed the above-named HCP's level of experience, past performance and quality indicators (if renewing privileges) as _.ated 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: Medical Record Review o HCP's Health and Mental Status Continuing Education Conferences Sentinel EventslRisk Management Reports 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 prlvileqes as requested, but subject ~onths. ~ o o IO/3e>/o?. ~ Service Center Administrator Collaborating Physician Signature Collaborating Physician Signature Collaborating. Physician Signature /( Medical Director Signature Revised ChV
13 , r: HCP Clinical Privileges Update Form N\ccla.. RR~A~fk- Department of Oh>Ia":"!:::lnDQ\O<'M -~o\i.l'p1 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): #0 Curre'nt Privileges not to be renewed: '" Privileges not 'renewed arc not reported Il3 being voluntarily rellnqulshed unless this Is done while you are under Investigation; or, in return Cornot conducting an lnvesttgation or proceeding. If prtvlleges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be flied with the National Practitioner Databank. I As the Supervising Physician/Of Liaison! Department Chair/Medical Directorl 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:... Medical Record Review HCP's Health and Mental Status Continuing Education Conferences Sentinel EventslRisk Management Reports o We find adonows: " W' 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 subjec _ revie months.
14 .P~ivilegeList for 17-Feb-OO Audiologist ~EASE 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 CATEGORY, 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. D The applicant will manage patients as an independent audiology function Comprehensive Audiologic Evaluation Cranial Nerve Assessment Evoked Potential Testing Hearing Aid EvaluationlFitting and Follow-up Intraoperative Monitoring New Born Hearing Screening Tinnitus and Hyperacusis Evaluation and Management Vestibular and Balance Evaluation and Management Cochlear Implant Evaluation and Management Central auditory processing disorders - Evaluation and Management Cerumen Management JTHER PRIVILEGES Neonatal Pcd Adol Adult Geriatrics D D D 1) D D b D D D D D D D D D D D D D B P5B ItF ~B IDE D 1\)\ B tjltt }\),\') Nltr- D D D D D D D D D D D D D D D /'J 1\'1 D D C) b C. C C c C DATE Audiologist Signa DATE As the Collaborating Physician and Department Chair/Division Chief, 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 audiologist's qualifications are appropriate..;j I :Z3/ 0" 1../23! od DATE j I. 2113/t?o ~rvisorsignature C Division Director Signature, I DATE Department Chair Signature ' Page 1 of 1
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