" AHP Clinical Privileges Update Form Robert Davis Department of Neurology have reviewed the privileges previously granted (copy attached) to me and r
|
|
- Victor Blair
- 5 years ago
- Views:
Transcription
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34 " AHP Clinical Privileges Update Form Robert Davis Department of Neurology 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 e hile you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be repor d as voluntarily relinquished you will be notified and receive a copy of the port to be filed with the National Practitioner Databank. As the Supervising Physician/QI 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 ~pointment, we have reviewed applicable information from the following sources of quality and utilization data: IYl" Record Review ~ Continuing Education Conferences [3' Physical & Mental Health related to Job Performance ~ Annual Evalua.tion o /Student Evaluation E1 Annual Review by Dept. Chair or SCA 0' Risk Management Events/Quality Management Reports for claims 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 subject to a r~"'2j int- months. jl l1 1\:) );.; lr~n't~ Frederick Wooten, M.D. ~ Primary Su ervising Physici n Signature Printed Name!.~'1-1 24(0 te Madal;ne B. Harr;son. M.D. Printed Name ~J. b/i> Daniel Larriviere, M.D. Date Printed Name ~~ Date Alternate Supervising Physician Signature Printed Name z/1j!o Karen C. Johnston, M.D. Date Printed Name revised 3/1/2005 Da~ Printed Name
35 ". AHP Clinical Privileges Update Form &/ovlf 6avc-s Department of Altlut()(~-LlL~. - have reviewed the privileges previously granted (copy attached) to me and requ~;z:;ollowldg 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 tiled with the National Practitioner Databank. 1 As the Supervising PhysicianlQI Liaison/Department Chair/ Director/ Service Center Admiriistrator, 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 ~ Continuing 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 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 are in months. l/;{t Lo «-=-:---r<-::--;''''f--:----=---='-:--f-=-~oat ~"'~!:'ng p~ Signatu," \![.,(( D~' }1~\A~Q.:...:"-'~..Ao..~,-- _ Date Alternate SURervising Physician Signature Printed A~~ Printed Name Name ~(S""- Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date OJJlttLt7t. Printed Name J(~~TI~~ Date Printed Name revised 3/1/2005
36 .> " AHP Clinical Privileges Update Form &hmf 6a.V(~ Departmentof AlWAO(OJi-=fJ _ ---'lave reviewed the privileges previously granted (copy attached) to me and request J:;ollowing 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 As the Supervising Physician/Qf 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 ~pointment, we have reviewed applicable information from the following sources of quality and utilization data: Record Review ~ Annual Evaluation ~ Continuing Education Conferences 0 Student Evaluation 0' Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA ~Risk Management Events/Quality Management Reports for claims ~ Prescriptive Other Privileges (8 hours continuing education documentation required every 2 years) _ We find as follows: ~ Acceptable review with recommendation of reappointment with clinical privileges as requested. Da Signature Printed Name Avdk:t' ~{S""-- Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date Printed Name ;:~tn~~ Printed Name revised 3/1/2005
37 AHP Clinical Privileges Update Form ----!~~()=_bvrl:=~=--~.:..:=..:...:v~~_=0= "Department of ---''---=:...;:..-!..C---"?'~+- _ "-~,I have reviewed the privileges previously granted (copy attached) to me and request New Privileges to be Added (please indicate category level and type of experience): ~ C-:t:.. <! c1. -?C v / 7 following changes: 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 report as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Da tj tit 0 r's As the Supervising PhysicianlQI LiaisoniDepartment 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 iyv Continuing Education Conferences IU1, Physical & Mental Health related to Job Performance err. Risk Management Events/Quality Management Reports for claims [l( Annual Evaluation o Student Evaluation 0'" Annual Review by Dept. Chair or SCA [i' Prescriptive Privileges (8 hours continuing education 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 ~equested, but SUbject>~areview in months. _I ~~\tuy if"!;f2j / -'- C..lllrk:~ u.9~:l... \ Dat~ ~rimary up, ising Physician ignature Printed Name,/., ~~(,,1- ( i /l'k~ il!forc/sc- f,i. fr~_ ~.d ~/Dat i / Alternate Printed Name ~ / ;;;A/o"] Joe:.l l ('v~ Name -u---- 1/ " -::J-:~-:--:-:-:>_- _..o::b'-c_~-vt_~_~_- D e Printed Name Clinical Care»n Ad. Printed Name,,0~!AJ64j -, ~!tltlu ~ ~ Chair/RPC DirectiSignature (for HSFemployees) Printed Name.' revised 3/1/2005
38 . ~ AHP Clinical Privileges Update Form ~&_u=-o:2..f::w,=------,-~_~i)~i~=- Department of--j.-..:::t=l~~..!.u~~::: ,- _ I have reviewed the privileges previously granted (copy attached) to me and reques /~Tew Privileges to be Added (please indicate category level and type of experience): e following changes: Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless thib'o/done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be r~or;:ted 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 PhysicianlQI 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: ~... Record Review [3(' Annual Evaluation ca' Continuing Education Conferences ~tudent Evaluation WPhysical & Mental Health related to Job Performance ca/annual Review by Dept. Chair or SCA W Risk Management Events/Quality Management Reports for claims ~Prescriptive Privileges (8 hours continuing education 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 a~tjon plan in place with recommendation of reappointment with privileges ~s requested, I but subject to a r~vrew}rv'" / i months",j l' r) / i,(i- >.Jf //1 l;,rl.//--'-/ r: ~ cl,l ute /(j ~Jk'-" v Y (A.> If\. 01.1: Ukrn D te'. Primary Supe i ising Physician Signature' print.ed Name. z b ob \...1'(, _ f ~ e&l.:. L 4.n=jJ5~ D,te, Alternate upe~ising PhYS~ignature ~a~e _ c>&~/i)(,. I. ji.{ ~...A. \CVJ~-.a/, Phy ici n Sig ature ~. me ~ ;;{ Z: 6 -> <l2..., il a1i1'1k;t/ ate Printed Name ~ Date I LIZ ItJD Oate ' # "..~ //. Clinical Care Svcs A in!.s. 'tator-'(foric,..('j' I,.:/,,/ :: /' employees) ~/ I, /,Iv ~.,-. '" ChairiRPC Director Signa}lire (for HSF employees) Printed Name Printed Name revised3/1/2005
39 AHP Clinical Privileges Update Form Departmentof -+~-=~~~~~~~ _ I have reviewed the privileges previously granted (copy attached) to me a request the following changes: New Privileges to be Added (please indicate category level and type of expe ience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquish unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privilege e to be reported as voluntarily relinquished you will be notified and receive a 0PY of th eport to be filed with the National Practitione tabank. 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 ~~ointment, we have reviewed applicable information from the following sources of quality and utilization data: o Record Review c1" Continuing Education Conferences [j Physical & Mental Health related to Job Performance [2f 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 eduacation documentation required every 2 years) Other _ We find as follows: ~ [2( 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()r)e~sted' but subject to a revi in ~nths. ~ u. ~ GFW;;;()k. o te ising Physician Signature Printed Name Date ~CO( Date 411 frm:i / rj r i? j@u-""u...::<:d::o.</c-:j"-- _ Printed Name.-- (,-:- J 11<.. \ vft\ (V'U.~'"1."- Printed Name r~-"----- TzfvhELME&Uff~ Printed Name k Printed Namr Gr(JOo~. Printed Name
40 AHP Clinical Privileges Update Form Department of ~~_e.vvt o_(_o-\: :::::r- }-J,lave reviewed the privileges previously granted (copy attached) to me an request the following changes: N 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 ss this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges ar to e reported as voluntarily relinquished you will be notified and receive a copy f the report to be tiled with the National Practitioner Da b k, As the Supervising Physician!QI 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: ~~ Record Review c, Continumg Education Conferences...:J Physical & Mental Health related to Job Performance []' Risk Management Events/Quality Management Reports for claims Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SeA u1 Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other _ We find as follows: rz( 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 revlew-ln onths. ) I I..-r;:; ~ 13c.., -" - 7' vt ' ~ batd Primary Supervi"ng Physician S.'gnature r...( "o( 00,! ~ ')-/~I ()'t o~ v(~'f Printed Name Date I ". IOJ!DY bate I Printed Name ~r WO,)*~ Printed Name revised 1/8/2003
41 Privilege List for: Family Nurse Practitioner 08-Jul-03 '~Name: k i4&? fzj4~/1&; Date: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULA Y 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 RE 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 andlor consultation with the physician. ~'1edical ~\1edical Aedical Congenital Heart Disease Rheumatic Heart Disease GI Disease Dif Dx & Tx Premature Disorders Dx & Tx Premie Growth & Development Neurological Dif Dx & Tx CNS Infections Psychophysiologic DifDx & Tx Renal Dif Dx & Tx Electrolyte & Water Balance Croup, epiglottitis Cystic fibrosis Pulmonary Dif Dx & Tx Pre & Post Op Cardiac Care Attention Deficit Disabilities Cerebral Palsy Head & Spinal Cord Injury Ped Learning & language disabilities Ped Mental retardation Pituitary Conditions Malabsorption General Peds Dif Dx & Tx Immunization Osteoarthri tis Rheumatoid Arthritis Rheumatic Fever. Acute Cardiac Rehab Neurodegenerative Disorders Endocrine!Metabolic DifDx & Tx. General Med Dif Dx & Tx Allergy/Irnmun Dif Dx & Tx. Arthritis Cardiovascular Dif Dx & Tx Birth Defects Eval Newborn Dif Dx & Tx Newborn screening Adjustment Problems Ped Behavioral Problems Cognitive Rehab Dialysis Mgt Neonatal Ped Adol Adult Geriatric C2 c:::. G C- L C- c: c. c: C- C (" I'"., C G L- C' c ~ r: C c: c: c. /J. /f A -: C- r: Page 1 of 5
42 ~ ~ 'rocedure /"~'l"ocedure ~rocedure RheumatologidVasc HIV,AIDS Immunodeficiency Health Geriatric Cholecystitis Pancreatitis Cirrhosis Maintenance Dif Dx & Tx Dif Dx & Tx Hepatic Diseases Dif Dx & Tx Gynecologic Routine DifDx & Tx Infertility Initial Eval & Mgt Sexual Infectious Diabetes Fractures Counseling Disease Dif Dx & Tx Mellitus & Dislocations Pediatric Emotional Disorders Dermatologic Diseases> Dx & Tx Drug Reaction CVA Rehab Anesthesia Local Anesthesia Regional & Overdose Pulmonary Function Testss EMG Audiometry Tonometry Slit Lamp Spirometry Percutaneous Exam PAP Smear Fetal Monitoring Incision/Drainage Skin Laceration Anoscopy Sigmoidoscopy EMG Biofeedback Arthrocentesis Arterial Bone Marrow Paracentesis Thoracentesis CPR Endotracheal Circumcision Blood Gas Skin Testing of Abscesses Repair Aspiration Intubation Norplant Insertion & Removal Breath Hydrogen Test Cryotherapy Lumbar Puncture Foreign Body Removal - Subcutaneous Foreign Body Removal - Subungual Foreign Body Removal - External auditory Foreign Body Removal> Vagina Wound Mgt- Assess for Functional Integrity Pulmonary Artery Catheter Manipulation Wound Mgt - Wound preparation Wound Mgt - Debridement Wound Mgt - Closure Wound Mgt Dressing Wound Mgt - Immobilization Neonatal Ped Adol Adult Geriatric L- e: C-? -: L -: r": r C- c. -- c- a 0 L1 /.),.q Ll L c. I C I Page 2 of 5
43 ~, General General General General General General General General General General General General General General, ' '~""rocedure _'rocedure Nail Avulsion IUD Insertion & Removal Pessary Insertion & Removal Allergen Immunotherapy Histamine Provocation Wound Mgt - Removal of Sutures/Staples Prenatal Counseling Impotence - Evaluation & Mgt Pain Management History and Physical Dx, Assessment Telephone & Mgt Triage/Consultation Hospital Rounds Admissions (with MD collaboration) Order - Labs Order - Urodynamic Studies Order- Order ECG - Echocardiogram Order - Holter Monitoring Order Order > Order Order - EEG Radiographs Consults Medications Nutritional Status - Eval & Mgt Peripheral Central Venous Line Placement Contraceptive Counseling Health Maintenance & Disease Prevention Cerumen Impaction Removal Ventilator Weaning Mgt Chemotherapy Intradermal Lab Test - Dipstick - POlIVlIntrathecal Skin Testing Lab Test - Cervical Lab Test - Urethral Lab Test - Rectal Lab Test - Throat Urinalysis Cultures Cultures Cultures Cultures Lab Test - Soft Tissue Site Cultures Lab Test - Blood Cultures Surgical Assist Surgical Drain Removal - Draw Tracheostomy Tubes - Remove Transtracheal Wound Aspiration Mgt - Electrocoagulation OB - Routine Prenatal & Postpart Eval & Mgt on - Intermed. Risk Prenatal & Postpart Eval & Mgt on - High Risk Prenatal & Postpart Eval & Mgt Cardiac Arrest- Assist Colposcopy - Cervical Biopsy/ECC Condyloma Microscope Tx's Eval - Urine Microscope Eval- Post Coital Cervical Mucous Microscope Eval- Breast Discharge Microscope Eval - Amniotic Fluid Intermittent Catheterization Tx Ultrasound. Fetal Ltd - Fetal Presentation Ultrasound - Fetal Ltd - Fetal Cardiac Activity Ultrasound- Fetal Ltd - Dating 1st Trimester Ultrasound - Fetal Ltd > AFI Neonatal Ped Adol Adult Geriatric c:::.. c... L L. C '-' /" /' L '? c. e I" C- c- 4 ~.'LJ a d3' fl /" ~ c::... --,.-::. C- c-»: c- G -: C- c:- /.. L L C- c: r e- c, c...- -: C 0 e. r r: L- C- C-- C r: C- C. c... C C C r: R A- /.f- Page 3 of 5
44 ,'----- " "---. "')rocedure General General General General General General General General Urodynamic Studies - Simple Office Cystornetrics Urodynamic Studies - Urodynamic Catheterization Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Percutaneous EMG Gouty Arthritis ICP Adjust Treatment Protocols Heme/One Hyperbilirubinemia Spinal Dif Dx & Tx Shock - Mgt Thromhophlebi Urologic Urticaria tis Disease - Dif Dx & Tx Adjust Pacemaker Settings Adjust Cardiac Assist Devices Ambulatory Halux 02 Saturation Camino Bolt Removal Hansel Smear - Nasal Secretions Intracardiac Catheter Removal Ornaya Reservoir TPN Ordering Typanornetry Ventricular Catheter Removal Conscious Diaphragm Sedation Fitting Biopsy - Endometrial Chest Tubes - Clamp and/or Remove Epicardial Pacing Wire Removal Doppler Monitoring of Fetus Ortho s - Nasal Ortho s - Ribs - Stable Chest Ortho s - Shoulder Dislocation Ortho s - Clavicle Ortho s - Upper Extremities Ortho s - Lower Extremities Pulmonary Artery Catheter removal Biopsy/Removal Biopsy - Vulvar - Skin Lesion Foreign Body Removal - Nasal Lab Test - Vaginal Cultures Serum Sickness Microscope Eval- Vaginal Secretions Authorized to Prescribe Evaluate - ECG Evaluate- Echocardiogram Evaluate - EEG Evaluate - Holter Monitoring Evaluate Evaluate - Labs - Radiographs Evaluate - Urodynamic Studies Dermatomyositis Nephrotic Disease Dif Dx & Tx Neonatal Ped Adol Adult Geriatric r: ~ c:;.- -: r:.zz- C-»: -: /'»: r ez: e: a: r: C- r: Page 4 of 5
45 OTHERPRIVll..EGES Neonatal Ped Adol Adult Geriatric Name Printed 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 DATE DATE Alternat Alternate G. Frederick Wooten, MD Name Printed el M. me Printed Trugrnan, MD Madaline B. Harrison HD Name Printed DATE Alternate Supervising Physician Signature Name Printed DATE Dept Chair or Svc Center Administrator Name Printed Page 5 of 5
AHP 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 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 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 informationX 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 informationRegions 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
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 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 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 Family Medicine Clinical Privileges
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 07/31/2015 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.
More informationUNMH Family Medicine Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective April 28, 2017: Initial Privileges (initial appointment) Renewal of Privileges (reappointment)
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 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 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 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 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 informationUPMC For Reference Only PHYSICIAN ASSISTANT 2014
Summary of Services and Availability (by location) Each location has sufficient space, equipment, staffing and financial resources in place or available in sufficient time as required to support each requested
More informationQualifications For initial appointment and core privileges in the Department of Family Medicine, the applicant must meet the following qualifications:
DEPARTMENT OF FAMILY MEDICINE Qualifications For initial appointment and core privileges in the, the applicant must meet the following qualifications: Successful completion of an ACGME or AOA-recognized
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 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 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 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 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 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 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 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 informationSPECIALTY SPECIFIC OBJECTIVES
Family Medicine Residency Internal Medicine In-house II Rotation Rotation Goal Admission, evaluation, treatment and appropriate specialty consultation of adult hospitalized patients from either the ER,
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 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 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 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 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 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 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 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 informationDELINEATION OF PRIVILEGES - FAMILY MEDICINE
KALEIDA HEALTH Name DELINEATION OF PRIVILEGES - FAMILY MEDICINE LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency
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 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 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 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 informationPRIVILEGE APPLICATION FORM - [Mercy Medical Center]
Current Privilege Status Key Practitioner's Current Privilege status is signified in ( ) preceding each privilege. G = W = Withdrawn T = Temporary P = With Proctor A = Assist with C = With Consult E =
More informationNurse Practitioner dictionary was approved by PMSEC on September 14, 2017
Summary Page NURSE PRACTITIONER DICTIONARY APPROVAL Nurse Practitioner dictionary was approved by PMSEC on September 14, 2017 REVIEW PANEL COMPOSITION The panel was composed of two co-chairs with expertise
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 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 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 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 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 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 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 informationClinical Privileges Profile Nurse Practitioner. Kettering Medical Center System
Printed Name Clinical Privileges Profile Nurse Practitioner Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested.
More informationAPPLICATION FOR CLINICAL PRIVILEGES (MEDICAL)
APPLICATION FOR CLINICAL PRIVILEGES (MEDICAL) Granting, reviewing, and changing of clinical privileges for the staff of FIRST CHOICE COMMUNITY HEALTHCARE (FCCH) will be in accordance with the FCCH policy.
More informationLeading Practices and National Benchmarks in Advanced Practice Clinician (APC)
Leading Practices and National Benchmarks in Advanced Practice Clinician (APC) Privileging, Competency Assessment and Leadership Structures Presented to: National Credentialing Forum March 2, 2017 Trish
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 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 informationRegions Hospital Delineation of Privileges Physician Assistant Emergency Medicine
Regions Hospital Delineation of Privileges Physician Assistant Emergency Medicine Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting.
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 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 informationDEVELOPMENTAL-BEHAVIORAL PEDIATRICS 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 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 informationSUTTER MEDICAL CENTER, SACRAMENTO Department of Family Medicine Delineation of Privileges
To request Privileges, please place an X in the request column. In box, indicate the number of identified procedures performed in previous 24 months from any Request Privilege Appointment [ ] Admit [ ]
More informationDEPARTMENT OF HEALTH NO No. R. 11 NOVEMBER
Health, Department of/ Gesondheid, Departement van 1390 Health Professions Act (Act 56 of 1974): Regulations Defining the Scope of Practice of Clinical Associates 40414 Reproduced by Sabinet Online in
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 informationMD or DO or equivalent International medical training
UPMC 1 Delineation of Privileges Request Criteria Summary Sheet Facility: Specialty: Childrens Hospital of Pittsburgh of UPMC, North PEDIATRICS KNOWLEDGE MD or DO or equivalent International medical training
More informationFamily Medicine Residency Surgery Rotation
Family Medicine Residency Surgery Rotation Rotation Goal The overall goal for the educational experience provided in the areas of general surgery, trauma surgery, office orthopedic surgery and sports medicine,
More informationCredentialing Application Packet. Dear Resident Applicant,
Credentialing Application Packet Salina Family Healthcare Center A Federally Qualified Community Health Center 651 E. Prescott, Salina, KS 67401 Medical Center ~ (785) 825-7251 Dental Center ~ (785) 826-9017
More informationN: Emergency Nursing. Alberta Licensed Practical Nurses Competency Profile 135
N: Emergency Nursing Alberta Licensed Practical Nurses Competency Profile 135 Competency: N-1 Multi-Systems Assessment N-1-1 N-1-2 N-1-3 N-1-4 Demonstrate knowledge and ability to apply critical thinking
More informationLICENSURE, CREDENTIALING, AND GRANTING OF CLINICAL PRIVILEGES
Licensure, Credentialing, and Granting of Clinical Privileges Chapter 6 LICENSURE, CREDENTIALING, AND GRANTING OF CLINICAL PRIVILEGES Joanna G. Sanford, PA-C, MPAS Introduction US Army physician assistants
More informationTo ensure oversight of resident supervision and graded authority and responsibility, the following levels of supervision are recognized:
Roles, Responsibilities and Patient Care Activities of Residents University of Washington Boise Internal Medicine and Saint Luke s Health Care System and Saint Alphonsus Health Care System Definitions
More informationCRITERIA FOR GRANTING MEDICAL PRIVILEGES
CRITERIA FOR GRANTING MEDICAL PRIVILEGES Please review these categories carefully to determine those privileges for which you are qualified. Indicate your request below by checking the appropriate category.
More informationEMERGENCY MEDICINE CLINICAL ROTATION COMPETENCY BASED CURRICULUM
CLINICAL ROTATION COMPETENCY BASED CURRICULUM EMERGENCY MEDICINE During the third year of the curriculum, students expand their knowledge of emergent conditions and gain the ability to apply the knowledge
More informationUWSMPH Clerkship Experience Requirements
2016-2017 UWSMPH Clerkship Experience Requirements Students will use OASIS to check off each Clerkship Experience Requirement. The following conditions, procedures and learning activities must all be completed
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 informationPhysician Application
CONTROLLED RISK INSURANCE COMPANY OF VERMONT, INC. (A RISK RETENTION GROUP) CONTROLLED RISK INSURANCE COMPANY, LTD. Physician Application Please type or print responses in ink, and answer all questions
More informationPolicy on Supervision: Roles, Responsibility and Patient Care Activities for Residents. Department of Medicine Internal Medicine Residency
Policy on Supervision: Roles, Responsibility and Patient Care Activities for Residents Department of Medicine Internal Medicine Residency Philosophy Residents are physicians in training. They develop and
More informationBasic Standards for. Residency Training in. Osteopathic Family Medicine. and Manipulative Treatment
Basic Standards for Residency Training in Osteopathic Family Medicine and Manipulative Treatment (Includes Rural Training Standards in Appendix III) American Osteopathic Association and American College
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 informationSupervision of Residents/Chain of Command
Supervision of Residents/Chain of Command Creighton University Department of Surgery Residency Training Program Chain of command for Surgery residents at CUMC PGY1: The intern on call covers the two general
More informationMetropolitan Chicago Healthcare Council (MCHC)
Emerging Trends All APNs Should TITLE Know OF to PRESENTATION Practice at Their License LORUM Ceiling IPSUM DOLOR October 10, 2014 Molly Harper, MHA Program Manager, Clinical Services Metropolitan Chicago
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 informationMartin s Point US Family Health Plan Pre-Authorization Requirements
Martin s Point US Family Health Plan Requirements Requirements described below are for covered benefits only and this information is provided for summary purposes only. Please call 1-888-732-7364 for complete
More informationNURSE PRACTITIONER (NP) CLINICAL PRIVILEGES ORTHOPEDIC SURGERY
Name: Page 1 Initial Appointment (initial privileges) Reappointment (renewal of privileges) All new applicants must meet the following requirements as approved by the governing body effective: / /. Applicant:
More informationHospitalist 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 informationTrauma Rotation UMASS Memorial University Campus
Trauma Rotation UMASS Memorial University Campus * The following objectives include goals and achievements set forth for successful completion in the acute surgery & trauma rotation such that residents
More informationPRACTICAL SKILLS. Objective examination of the patient
RACTICAL KILL tudent's data. These fields are completed by the student First and last name No of study book In the next tables, total of 76 practical skills are listed by topics that you should develop
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 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 information2016 SUMMER STUDENT NURSE EXTERNSHIP PROGRAM SKILLS CHECK LIST
2016 SUMMER STUDENT NURSE EXTERNSHIP PROGRAM SKILLS CHECK LIST STUDENT NURSE EXTERNNAME SCHOOL OF NURSING STUDENT AGREEMENT: I request the Clinical Skills Check list be released to (hospital/agency). I
More informationI: Neurological/ Neurosurgical
I: Neurological/ Neurosurgical College of Licensed Practical Nurses of Alberta, Competency Profile for LPNs, 3rd Ed. 81 Competency: I-1 Neurological Nursing I-1-1 I-1-2 I-1-3 I-1-4 Demonstrate knowledge
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 informationAPP PRIVILEGES IN OTOLARYNGOLOGY
APP PRIVILEGES IN OTOLARYNGOLOGY 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
More informationE: Nursing Practice. Alberta Licensed Practical Nurses Competency Profile 51
E: Nursing Practice Alberta Licensed Practical Nurses Competency Profile 51 Competency: E-1 Critical Thinking E-1-1 E-1-2 E-1-3 Demonstrate knowledge and ability to apply critical thinking concepts throughout
More informationSPECIALTY OF FAMILY MEDICINE Delineation of Clinical Privileges
SPECIALTY OF FAMILY MEDICINE Delineation of Clinical Privileges Criteria for granting privileges: Current board certification in Family Medicine by the American Board of Family Medicine or the American
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 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 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 informationUNMH Pediatric Nephrology Clinical Privileges
ll new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 07/31/2015 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.
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 informationBasic Standards for. Residency Training in. Osteopathic Family Medicine. and Manipulative Treatment
Basic Standards for Residency Training in Osteopathic Family Medicine and Manipulative Treatment (Includes Rural Training Standards in Appendix III) American Osteopathic Association and American College
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 informationPenn State Milton S. Hershey Medical Center. Division of Trauma, Acute Care & Critical Care Surgery
Curriculum Penn State Milton S. Hershey Medical Center Division of Trauma, Acute Care & Critical Care Surgery Residency-SICU The Section Chief for the Emergency General Surgery section within the Division
More information