AHP Clinical Privileges Update Form Kimberly Skinner, P A Department of Neurosurgery /-,j:have reviewed the privileges previously granted (copy attach
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32 AHP Clinical Privileges Update Form Kimberly Skinner, P A Department of Neurosurgery /-,j:have reviewed the privileges previously granted (copy attached) to me and request the following changes:.~ew Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. ~'----- Date Practitioner's Signature ~ As the Supervising Physician/QI Liaison/Department 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data: o Medical Record Review o Continuing Education Conferences o Physical & Mental Health related to Job Performance o Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o 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: o 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 iew in months. (/UQ/01 Date Prim Gregory Helm, M.D. Printed Name John Jane, Sr.. M.D. Date Printed Name W. Jeffrey Elias. M.D. Date ure Printed Name Christopher Shaffrey. M.D. <. Date Printed Name Date Clinical Printed Name Mark. E. Shaffrey, M.D. Date. nature (for HSF employees) Printed Name revised 3/1/2005
33 ,, Kimberly Skinner, PA Privilege Update - Additional Supervising Physicians Date Date Date cf3-.2.cr - 01 Date Neal Kassell. M.D. Printed Name Aaron Dumont. M.D. Printed Name Ladislau Steiner, M.D. Printed Name John Jane. Jr., M.D. Printed Name Cj - 3-l)CI Date ising Physician Signature Jason Sheehan, M.D. Printed Name Date Edward Oldfield. M.D. Alternate Supervising Physician Signature Printed Name Date Justin Smith, M.D. Printed Name
34 AHP Clinical Privileges Update Form \0t~ S~~ Department of N(,.{).J(QJ~ _ ~I have reviewed the privileges previously granted (copy attached) to me and reques~g 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 Invesnganon or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Date Practitioner's Signature As the Supervising Physicianf:QI LiaisonlDepartment ChairIMedical Director/ Service Center Administrator, we have reviewed the above-named AH'P'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: ~ ~~ , 51 Medical Record Review Annual Evaluation Gt Continuing Education Conferences 0 Student Evaluation G(Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA d Risk Management Events/Quality Management Reports for claims iijiprescriptive Privileges (~:hours continuing education documentation required every 2 years) Other _ We find as follows: ri Acceptable review with mcommendation of reappointment with clinical privileges as requested. o Concerns noted on review as requested, but subject fj/-l{&!j lth corrective action plan in place with recommendation of reappointment with privileges a review in months. Chq ~~ \url S\\a-S ~ Printed Name. -:s b\'\ ~ :::>OJ\H. i t, t Printed Name / fv~ ~\~c..w..."3..\ ~~ ~J ia.~tlj~ Printed Name 4Ar\C ShcJ -ffi!! \~ I
35 revised 3/1/2005 atel 10/5"(01 D~deI!o/3b 1 date, Alternate sup. ervising Physician Sig:.::ure" "" ~:::r::> 5( -- Alternate Supervising Physician Signature Printed Name ::so.f,ly\ Printed Name Printed Name SV\g.XV!... \ \v0 I
36 AHP Clinical Privileges Update Form lave reviewed t e privileges previously granted (copy attached) to me and r t t e following changes: I~ew Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Date As the Supervising Physician/QI LiaisonlDepartment ChairlMedical 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: / -,~ Medical Record Review ~ontinuing Education Conferences Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA &"..Physical & Mental Health related to Job Performance ~ Risk Management Events/Quality Management Reports for claims o 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 orrective action plan in place with recommendation of reappointment with privileges as requested, but subject to ale view i months. 0;/;'I (D5 (b.~4j. M~l~~ Date Printed ~m~ \ Date t(~~/~ {b/~b5 Oat /v!~~~ ~ <. Date ~ {C)/~/()5' lrector S,gure (for HSF employ s) ~ \~"2e\\ \-A:.-..::~ _ Printed Name \ Printed Name E~~ L~ ~ Printed Name 00 C(S-\-7J\»H:.c ~G..~'\(\ll ~ Printed Name \ "30 nv-- f\.~j...? '0r, I \02 Printed Name I I \'
37 ...--' 1~2-:S--~ Date, tj~ Alternate Supervising Physician Signature Alte ~I \'~~ ~~~ t.~a2\~ Name Printed \ Name Printed, Q"'d-.1-S'""' Date Alte Name Printed ~ Date Alternate Supervising Physician Signature \.o..a~"':l \ ~v,.u- ~ Name Printed Date Alternate Supervising Physician Signature Name Printed
38 .r:l.j...la..,-,iiuh.. Ql.J.. I Jl'Jl\...i;;.\...\l LJtJual.~.J..'UIIII l<rfhbvj {{~(h.~i fa Departmentof-l-~~~~~~\-7- _ I have reviewed the privileges previously granted (copy attached) to me and request the 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/J5,/f23 ~ _ Date -f( practi~ture~ As the Supervising Physician/QI LiaisonlDepartment ChairlMedical 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: cg/medical Record Review. Annual Evaluation cg/continuing Education Conferences o Student Evaluation ifyhysical & Mental Health related to Job Performance Annual Review by Dept. Chair or SCA B" Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other _ 16 We find as follows:, P.cc~ptabtt; :'.wiew 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 =-D~ It,! IIC:..-'5'-- {of"/b~ :D~a--:t~ ~I~oit~-v3~ Datr-t ~7/-oli/~63~-~---- Date rt JD-l-~3 --~~.--~-~~ ~ Date f.d,,"b ~ I.. ate ~rz'~~5~~ ~~~~~~~, _ ~~~~~~~~~----~~~~~~~l~ nrv~c..;w) "'5;~t'\ 1=. '!o.."j~\ ~ v.~
39 Privilege List for Physician's Assistant 22-Jan-03 Name:,?\W\~ r\-. S 'pi V\V\Q..V Date: ~r-j03..c...-_ PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACfICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WInCH YOU DO NOT REGULARLY PRACfICE. 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 PRIVll..EGE: 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. General General General General General General General General General General General General General General Order - ECG Order - Labs Order- EEG Order - Radiographs Order - Holter Monitorin.~. Order - Echocardiograrn Order Medications Order Consults Hospital Rounds Patient Education History and Physical Authorized to Prescribe Chest Tubes - Insertion & Mgt Anesthesia Local Lumbar Puncture Wound Mgt - Removal of Sutures/Staples Thoracentesis Wound Mgt - Debridement Arterial line placement Cath Swan Ganz catheter placement Insertion, Catheter - Bladder Feeding tube Placement Venous cutdown Venipuncture Order - Diet Order- EMG IABP - Placement & Management NG Tube Insertion Catheter - IV Peripheral- Placement & Mgt ECG Administration Halo Vest - Adjustment Halo Vest - Pin Care Halo Vest - Placement Injections - Intradermal Injections - Intramuscular Intradermal Skin Testing IV Medications & Fluids - Administration Suturing - Major Suturing - Minor Neonatal Ped Adol Adult Geriatric t....' C- e: C C/ C «. G If ~ k c, :lr- C- r c. G..- c. c. C- c... C a. e: i c.,.., C- c. C- {-f- J4- t-- ~ Ii-- If- /--- J'} '-" A-' -ן ft' f'-" k F-- jj---.. c- r-. C- r= C- I-!-- ~ r1--- flr. C- A- A- (/> C- /. r r: /) r C r L- 4-..fir. c- f2.. I') r: C-- Page 1 of 2
40 - Surgery Assist - 1st & 2nd Assisting Surgery Assist - Harvesting Vein Surgery Assist - Position & Prep Injections - Intravenous General Evaluate - ECG General Evaluate - Echocardiogram General Evaluate - EEG General Evaluate - Holter Monitoring General Evaluate - Labs General Evaluate - Radiographs OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric B t> o- A-- #- ;f r {t-- G A--' A----,A--,Lv A--' -,.4--- /Y-- (J f) A- Ir' DATE l\zy\_q~ _ ~~~ --=-..J-ll ~.LL:~= !.~---=-:'Yn...:..:.~t\=S bnn~f?1t-. Signature Nam~ed 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 1/2--0'/; DATE " 3CJCJ3 I I ~- I(Xl0:;' DATE DATE DATE t(30f3 Name Printed Page 2 of 2
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