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21 -.. AHP linial Privileges Update Form <, NonnaBranham, GNP Department of Mediine I have reviewed the privileges previously granted (opy attahed) to me and request the following hanges: New Privileges to be Added (please indiate ategory level and type of experiene): urrent Privileges not to be renewed: * (\:In-e,, *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not onduting an investigation or proeeding. If privileges are to be reported as voluntarily relinquished you will be notified and reeive a opy of the report to be filed with the National Pratitioner Databank. 116!-'\.../VV'-i)) fba ~\ (Vvv'---' Pratitioner's Signature As the Supervising Physiian/QI LiaisonlDepartment hairl Diretor/ Servie enter Administrator, we have reviewed the above-named AHP's level of experiene, past performane and quality indiators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifiations are appropriate. Sine the date of the last -, -appointment, we have reviewed appliable information from the following soures of quality and utilization data: D Reord Review ~ ontinuing Eduation onferenes We find as follows: ~eptable review with reommendation of reappointment with linial privileges as requested. D onerns noted on review with orretive ation plan in plae with reommendation as requested, but subjet to a review in months. of reappointment with privileges Julia onnelly. M.D. Printed Name Aval Green. M.D. Printed Name Date Printed Name Date Printed Name Lorna Fateau, Administrator Printed Name Date hairfrp Diretor Signature (for HSF employees) Printed Name revised3/1/2005
22 Norm~&a.nftlh\ AHP linial Privileges I have reviewed the privileges previously granted (opy attahed) Update Form Department of!yl..tdr {f\.jl.- Q", (~.:s to me and request the following hanges: New Privileges to be Added (please indiate ate~ory level and typeof experiene):, i ~'b0 \ (\~ b NA M ~ ~ ~fyl'v)..q b r. E'v 0..""',<) <P1 1Jr (0 nr'] 'U.Lp p+,-s ~ 'S n I 0 ~ d f' U::..k. QI\-\- i.f I (,a.a"::'l:> ) D r, f Vl./"YlQ ~ ljl". (on n ~ pi..s urrent 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 onduting an investigation or proeeding. If privileges are to be reported as voluntarily relinquished you will be notified and reeive a opy of the report to be filed with the National Pratitioner Databank., I Date l1kyvloq\ K. &~~ GNP Pratitioner's Signature As the Supervising Physiian/Qf Liaison/Department hairl Diretor/ Servie enter Administrator, we have reviewed the above-named AH:?'s level of experiene, past performane and quality indiators (if renewing privileges) as _ related to requested privileges and agree that the above named AHP's qualifiations are appropriate. Sine the date of the last 'rppolntment, we have reviewed appliable information from the following soures of quality and utilization data: ff Annual Evaluation o Student Evaluation ~ Annual Review by Dept. hair or SA \. Reord Review g' ontinuing Eduation onferenes ~Physial & Mental Health related to Job Performane ~'Risk Management Events/Quality Management Reports for laims QI Presriptive Privileges (~;hours ontinuing eduation doumentation required every 2 years) Other _ We find as follows: // r;j/aeptable review with mommendation of reappointment with linial privileges as requested. o onerns noted on review with orretive ation plan in plae with reommendation of reappointment with privileges as r qu sted, but subjet' to a review in // months..' 1 A /Ir. 1h1\R. 1 \; ' ~~N~~~.-~-~~--y~~yate Printed Name Date :fu\tq G&t\M~~~ Printed Name 0 Date Altern :de Supervising Physiian Signature /-.~ Date fol,o. 107 ~ Printed Name Printed Name ---'1t~Rer. -S-Hazr M/I~ Printed Name Date hair/rp Diretor Signature (for HSFemployees) Printed Name
23 Privilege List for: Adult Nurse Pratitioner 31-Aug-06 Name: ~~ It Date: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRATIE; EMERGENY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO OVER AN AREA IN WIllH YOU DO NOT REGULARLY PRATIE. AREAS IN WIllH YOU DO NOT REGULARLY PRATIE SHOULD BE LEFT BLANK. AORDING TO THE ATEGORY BELOW, ENTER A, B, OR IN THE OLUMN NEXT TO THE LISTED PRIVILEGE A The appliant will not undertake patient management exept in emergeny. B The appliant will manage patients with physiian present. The appliant will manage patients in ollaboration and/or onsultation with the physiian. ~ '~'>roedure.'roedure Anesthesia Regional Pulmonary Funtion Testss EMG Audiometry Slit Lamp Exam Spirometry PAP Smear EMG Biofeedbak Arthroentesis Thoraentesis PR Endotraheal Intubation Breath Hydrogen Test Osteoarthri tis Rheumatoid Arthritis Rheumati Fever - Aute Neurodegenerative Neurologial Psyhophysiologi Pulmonary Disorders Med Dif Dx & Tx Dif Dx & Tx Dif Dx & Tx Dif Dx & Tx Hepati Diseases Dif Dx & Tx Gyneologi Routine Dif Dx & Tx Infetious Disease Dif Dx & Tx HIV, AIDS Eletrolyte & Water Balane Pituitary onditions Drug Reation & Overdose VA Rehab Foreign Body Removal - Vagina Rheumati Heart Disease Wound Wound Wound Mgt - Debridement Mgt - losure Mgt - Dressing Wound Mgt - Immobilization Histamine Provoation Wound Mgt - Removal of Sutures/Staples Urologi Disease - Dif Dx & Tx Impotene - Evaluation & Mgt Dx, Assessment & Mgt Neonatal Ped Adol Adult Geriatri ('. -, (., ( ( <, (' \' (I (', e, ~ ~ (' ' (' (' Page 1 of 4
24 -r=-, Genera! 'roedure Patient Eduation Rheumati Heart Disease Admissions (with MD ollaboration) Order Ventilator Nutritional onsults ontraeptive Weaning Mgt Status - Eval & Mgt ounseling erumen Impation Removal hemotherapy - POlIV/Intratheal Peripheral entral Venous Line Plaement Lab Test - Dipstik Urinalysis Lab Test - ervial ultures Lab Test - Urethral ultures Lab Test- Retal ultures Surgial Drain Removal Wound Mgt - Eletrooagulation Mirosope Mirosope Mirosope Eval - Urine Eval Vaginal Seretions Eval Post oital ervial Muous Urodynami Studies> Urodynami atheterization Gouty Arthritis Heme/One Dif Dx & Tx Spinal Shok - Mgt Urtiaria Adjust Paemaker Settings amino Bolt Removal TPN Ordering Ventriulostomy atheter Removal Adjust ardia Order Order> - Ehoardiogram EEG Assist Devies Foreign Body Removal Serum Sikness Evaluate > Ehoardiogram Nasal Evaluate- Radiographs Evaluate> Urodynami Studies Pulmonary Artery atheter Manipulation Paraentesis Foreign Body Removal- External auditory Typanometry Wound Mgt - Wound preparation holeystitis Epiardial Paing Wire Removal Foreign Body Removal «Subungual Omaya Reservoir Wound Mgt. Assess for Funtional Intraardia atheter Removal Hansel Smear Geriatri Ambulatory Thrombophlebitis Nasal Seretions Dif Dx & Tx Halux 02 Saturation Pulmonary Artery atheter removal irrhosis Infertility Arterial Initial Eva! & Mgt Blood Gas Bone Marrow Aspiration Authorized Mirosope to Presribe Eval - Breast Disharge Integrity Neonatal Ped Adol Adult Geriatri - <. (' ~.,. <:. ('. <" ' (" <:.. (" < ( ( s., Page 2 of 4
25 ~<" ~" Dermatomyositis Panreatitis Lumbar Punture Foreign Body Removal> Subutaneous Order - Radiographs Order- Holter Monitoring Order EG Surgial Assist Lab Test- Blood ultures- Draw Lab Test- Soft Tissue Site ultures Order Mediations Lab Tesr- Throat NS Infetions History Transtraheal and Physial ultures Aspiration Lab Test Vaginal ultures Health Maintenane & Disease Prevention Intradermal Skin Testing hest Tubes > lamp and/or Remove Immunization Sigmoidosopy IP Adjust Treatment Protools Urodynami Studies- Perutaneous EMG Allergen Immunotherapy Urodynami Studies- Retal Tube Insertion Urodynami Studies - Simple Offie ystometris Intermittent atheterization Tx Traheostomy Tubes- Remove Order» Urodynami Studies Telephone Triage/onsultation Hospital Rounds Pain Management Evaluate- Holter Monitoring ardia Tonometry Rehab RheumatologilVas Evaluate- EEG Renal Dif Dx & Tx Anesthesia Loal Endorine!Metaboli Dif Dx & Tx Dif Dx & Tx. Evaluate- EG AlIergylImmun Dif Dx & Tx ardiovasular Order» Labs Diabetes Mellitus Inision/Drainage Dif Dx & Tx of Absesses Dermatologi Diseases> Dx & Tx Anosopy Evaluate Labs Perutaneous Skin Testing GI Disease Die Dx & Tx Nephroti Disease Dif Dx & Tx Pre and Post-Op ardia are Head & Spinal ord Injury Malabsorption Arthritis Immunodefiieny Health Maintenane w d~ 3JN(\ 5 (~ 1"\ D-e.\.,-\ h Neonatal Ped Adol Adult Geriatri <2., r '- (' <, <, e ( (' ( -, ( <, ' <'.. - <, <.,. - (' <: -.-, ~ _ <. Page 3 of 4
26 _?roedure Sexual ounseling Fratures & Disloations Skin Laeration Repair Norplant Insertion & Removal Nail Avulsion IUD Insertion Pessary Insertion ondyloma Tx's onsious Sedation Diaphragm Biopsy/Removal & Removal Fitting Ortho s & Removal - Skin Lesions - Nasal Ortho s - Ribs - Stable hest Ortho s Ortho s - Shoulder - lavile Disloation Ortho s Ortho s Ortho s - Upper Extremities - Lower Extremities - Lower Extremities Rheumati Heart Disease OTHER PRIVILEGES. <, <. Neonatal Ped Adol Adult Geriatri.. (' <, <.. DATE Signature Name Printed As the ollaborating Physiian and Department hair/servie enter Administrator, we have reviewed the abovenamed pratitioner's level of experiene, past performane and uality indiators (if renewing privileges) as related to requested privileges and agree that the above named ratitioners qu ifiatins are appropriate. DATE ~11J>- ( tit,{ /vb DATE., Name Printed Name Printed DATE Alternate Supervising Physiian Signature Name Printed DATE DATE 3-d.-07 Alternate Supervising Physiian Signature Name Printed linial Administrator Name Printed H~R.u.Ar< -r. St-loR.'I Page 4 of 4
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
AHPClinical 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
AHPClinical 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:
X 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
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