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34 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 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 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/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: g Medical Record Review [i2(.continuing Education Conferences Gt' Physical & Mental Health related to Job Performance Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA Gt Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ~ ~ We fin51as follows:. ~cceptable review with recommendation of reappointment with clinical privileges as requested. Alan Matsumoto. M.D. John Angle. M.D. UlkliJlTurba. M.D. Alternate SupeiViSif19PhYsiCiiri Signature Saher Sabri, M.D. ployees) Printed Name t Datf/ Alan Matsumoto, M.D. revised 3/1/2005

35 Joseph Fallon, PA Privilege Update - Additional Supervising Physicians Practiti~ ~ ~..t" i c~ L..- toc\(-- On s Inature :E 11 IQ\/l :,.-'/l<:: it:j(..~u-~ AI~ e Supervising Physician Signature Alternate Supervising Physician Signature Wael Saad, M.D. Auh Whan Park, M.D. Alternate Supervising Physician Signature Alternate Supervising Physician Signature

36 AHP C~inical Privileges Update Form Joseph Fallon, PA Department of Radiology I have reviewed the privileges previously granted (copy attached) to me and request the following changes:.r+>. 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 tiled with the National Practitioner 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data: Medical Record Review ~nnual Evaluation ~ Continuing Education Conferences o )ltudent Evaluation GJ!lhysical & Mental Health related to Job Performance B" Annual Review by Dept. Chair or SCA [IV 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: ~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 r quested, but subject to a review in months.,~~. Alan Matsumoto, M.D. John Angle, M.D. Ulka Turba, M.D. r Saher Sabri, M.D. Clinical Care Svcs Administrator (for Me employees) Chair/RPC Medical Director Signature (for HSFemployees) revised3/1/2005

37 Joseph Failon, PA Privilege Update - Additional Supervising Physicians o\;0.' c, '7/d-3/07 Alt te Supervising Physician Signature /0~~~ Alternate Supervising Physician Signature Nadine Abi-Jaoudeh, M.D. Wael Saad, M.D. Auh Whan Park, M.D. Alternate Supervising Physician Signature Printed Name

38 AHP Clinical Privileges Update Form Joseph Fallon Department of Radiology 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): 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. ~>Medical Record Review Annual Evaluation g-j Continuing Education Conferences, 0 Student Evaluation ~ Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA ci Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other. We fi{id 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 review in onths. I-'Z~ -()1 Alan Matsumoto. M.D. John Angle. M.D. \ t/t?1 M\ Ulku Turba. M.D. Saher Sabri. M.D. Clinical Care Svcs Administrator (for Me employees) Chair/RPC Medical Director Signature (for HSF employees) revised 3/1/2005 _-'t

39 .iosepn r-auon, 1"1-\ r-nvueqe upnate - Aocmonai supervremq i-nysrcians Nadine Abi-Jaoudeh. M.D. ignature Alternate Supervising Physician Signature Alternate Supervising Physician Signature Alternate Supervising Physician Signature

40 AllY Clinical Privileges Update i"orm J oseph Fallon, PA-C Radiology Departmentof _ 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):, 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 Investlgation 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. Ih /D<t ~\ G?I~"" (; <"- Practitio~n;ture - As the Supervising Physician/Ql Liaison/Department Chair/Medical 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: o Medical Record Review o Continuing Education Conferences o Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Physical & Mental Health related to Job Performance Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (E:hours continuing education documentation required every 2 years) Oilier _ We find as follows: o Acceptable review with wcommendation o of reappointment with clinical privileges as requested. Bulent Arslan, M.D. Saher Sabri, M.D. fatlioej 0'les A. Amalu! 'l DalP MJJ CJUi I(ftW'\ revised 3/1/2005

41 JosephFallon, PA-C Privilege Update - Additional Supervising Physicians Nadine Ahi.Jaoudeh, M.D. Altermi'teSupervising Physician Signature Alternate Supervising Physician Signature Alternate Supervising Physician Signature Alternate Supervising Physician Signature.~.

42 .~&f'h frfloo Department of E<o..d(o(o&i I have reviewed the privileges previously granted (copy attached) to me and request the ollowing 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 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. I -J q practitionb~u;ture ~~t-=\-~g_-:n.,j...;;;nll=-=-cj'_v\. _-'--- As the Supervising Physician/QI LiaisoniDepartment Chair/Medical Directorl 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: gj Medical Record Review G( Continuing Education Conferences Gr J>hysical & Mental Health related to Job Performance Annual Evaluation o ~tudent Evaluation Ii:Y Annual Review by Dept. Chair or SCA G::( Risk Management Events/Quality Management Reports for claims. 0 Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Ofuer _ We find as follows: o Acceptable review with recommendation of reappointment with clinical privileges as requested. Cite }j )...1\O~ p?t~1ar; ---ror-- (b,imo revised 3/1/2005

43 .Joseph Fallon, PA Privilege Update - Additional Supervising Physicians.---, _ l7-1'l.o(~t Alternate Supervising Physician Signature Alternate Supervising Physician Signature Alternate Supervising Physician Signature

44 ~ ~. Q asc ~ t4jj.p n Department of '. d (0 D I have reviewed the privileges previously granted (copy attached) to me an q est 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 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. pmtitio{if.,*",f&~ (1; -L< 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 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 Risk Management Events/Quality Management Reports for claims o Prescrip ive Privileges (8 hours continuing eduacation documentation required every 2 years) Other "T rim wdwtcln o Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA We find as follows: 'tt Acceptable review with recommendation of reappointment with clinical privileges as requested. o (I<d-f(-~ h_/j..!/o( ing Physician Signature Ulk.u 0/1 & (Vtrt; c< Printed Name F employees) revised 1/8/2003

45 '1 Privilege List for: Physician's Assistant 22 Jun 05 Name: : t ( PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD DE MARKED ''''HERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN wmca YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFf BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PlUVILEGE 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 Monitoring Order «Echocardiogram 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 Surgery Assist ~1st & 2nd Assisting Neonatal Ped, Adol Adult Geriatric' ta.,fj -r.c r.., -I-. /0' r c. C /JJI) - i: C c.. c. c.~ & B fj f5 /2; 'P; h ;:; b f3 C (~.. C,77 -r r. ( r -l- e (-,-...- C c r. (' r C (~ r r--. ( r: /<j ;-:; C c c- IJ. Jh g n! r/ C C/ r: -~ 72. /2, A C r: C- D C ~ -g -g p 8 t c c r c. A C C r? 7f 7: ~ f3 I -,. ""(, I'>?' / r c, I- A ~, f4!s r 'I. r": r C- r. f',. r: (. c /. f" r.. ( c ;..} ia-- '5 C. c. ( c {' ( C ( C R t: c L. r' )tl/:>- '/lip 1\/ 51 ~ Ii. (" e. r ~ r r. r L WI- ( ~ /-./ C" c. {~ C C- f' (', r. f' r~ i' (/,.~ ~, 8 ~ ~ " f" Page 1 of 2

46 Procedui-a 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 Intubate Re-open Explore Chest Bronchoscopy Mini Tracheostomy Place trans-venous pacer OTHER PRIVILEGES {~?vj?uf fl --~~~~~~~~~~~~~----~--~----~~--- V /}1J1i.('b. --t~ _- Id I} /\/A ija IA (~ I) IV. C; A;--;j(w.:i:e Iln~- ftt,t I/{ f~ Ji'~ 11t {: I t1j,..v c:'g 7 J D~ ~l L Were,,- ~-G '- b-;(;m f, rald-j e.'l... DATE ~ sr: Name r (' r r 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. A It r t, DATEc/. '"~\.,---~\_/ DATE ~ b"[1j1/0r;- _ ~ IL~!/i4!1!//)mt(~10 Primary Supervising Physician Signature Name Printed Jo\ DATE 1/L1/0( DATE/ Page 2 of 2

Penrose-St Francis Hospital

Penrose-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 _ ***************************************************************