~ """ "' ",,,_,,,,"~'","~-m-_ '",_,~ Clinical Privileges Update Form Jamieson Bourque Department of Medicine I have reviewed the privileges previously granted to me and request the following chauges to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): -~'~--~-~"-~"'--"~-"'--"'---"'--"'--"--"'---'.--...~---- Current Privileges not to be Renewed: if Privileges not renewed are not reported as being voluntarily relinquished unless is done while you are under investigation; lor, In return for not conducting an investigation or proceeding. Ifprivileges 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 Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the above named clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date ofthe last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We fi~~llows: ~ ~~ceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. Should have clinical privileges granted but restricted as follows: lawrence Gimple. MD ~"------.,..._-.--.---- Division Chief/Quality Liaison DATE IAISON SIGN RE Mitchell Rosner, MD J/r/I) Interim Department Chair DATE Revised 31111006

~ - Rt=QUEST FOR CLINICAL PRIVILEGES Department of Medicine Year(s) of Certification Admitting Privileges? ayes o No PLEASE 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 OOVERANAREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU. DO NQTREGULABbXPBACTICI; SHOULD BE LEFT BLANK. Category A Category B The will not undertake patient management except in emergency. The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties. CategoryC Type 1 Type 2 Type 3 Type 4 I~-~~~ ~-~~.-------.-- The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally. According to type, enter 1, 2, 3 Internal Formal Specialty Training Program Limited Experience - without formal training ---~..---------- ----- ---.~--- ~CATEGORY ~- Extensive Experience - without formal training column. -.- -TVP-E---l ~~ I PRIVIL EGES REQUESTED Af{EA::i REQUESTED EXPERIENCE I I I - (A, B 0' C) (1.2 3 &/014) - - - - - - LLE c c, g Asthma Hay fever Serum sickness Urticaria Other

NIOOM 100M With acidosis

HEPATOBILIARY DISEASES With bleeding varices Decompensated GENERAL MEDICINE ANDREHABI DISEASES ~--~...---...... _--------

With shock DISEASES PU""V''-''~'''''' RENAL UIi:)CI"',i:)!::i:)

- -- --~---~~------ ---------- ------------- I. MEDICAL (cont'd) Page 5 ~ _~ ~ _ ~ ~ ~~_~w ~ ~ ~ CATEGORY TYPE PRIVILEGES REQUESTED AREAS REQUESTED EXPERIENCE (A, BorC) (1. 2. 3&lor4} RHEUMATOLOGIC DISESES, Differential diagnosis and treatment VASCULITIS AND DISEASES OF IMMUNOLOGIC ORIGIN TRANSPLANT MEDICINE -------- ---- --- --- ---~~ --- --- -- ----- - - ----~------- catego,ry A Category B II. PROCEDURES ------ --- - --- -- -- - -- - According to category, enter A, B or C in the REQUESTED column. The aoollica will not undertake procedure except in emergency. The applicant will occasionally perform or assist in the performance of the procedure. Consultation will be sought in the event of anticipated or actual difficulties. Category C Type 1 Type 2 Type 3 Type 4 The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. According to type, enter 1, 2, 3 and/or 4 in the I-r\rlm:::aI Internal Medicine Formal Specialty Training Program Program Limited Experience without formal training Extensive Experience - without formal training column.

-... -~~- - --- ------------- ----~-- ~---~ II. PROCEDURES (cont'd) Page 6 ~---- -----------------------~--- --- ---- ~. ------- - -- -- --~ CATEGORY TYPE PRIVILEGES REQUESTED AREAS REQUESTED EXPERIENCE (A B or C) (1. 2. 3 & lor 4) ALLERGY AND CLINICAL Intradermal skin testing IMMUNOLOGY (cont'd) Percutaneous skin testing Other ASPIRATION PROCEDURES Arterial blood gas C ~ INVASIVE CARDIOVASCULAR PROCEDURES Bone marrow aspiration Culdocentesis Nasogastric (e.g. gastric analysis) Joint aspiration Lumbar puncture C d- Paracentesis. C ~ Thoracentesis c.. ~ Thyroid Nodule Transtracheal aspiration Other AICD insertion Balloon pericardiotomy Balloon valvuloplasty Coronary artherectomy Coronary stent placement Diagnostic cardiac catheterization Electrophysiologic studies IABC A ;l Intrapericardial catheter placement Laser angioplasty Pericardiocentesis A ;J.. Permanent pacemaker insertion PTCA Radiofrequency-catheter ablation Temporary cardiac pacing C ~ Other CRITICAL CARE MEDICINE Arterial cannulation C Q... PROCEDURES Cardiopulmonary resuscitation C :L Chest tube insertion Endotracheal intubation Pr 1 Mechanical ventilation C.1 Placement of central IV lines I C ;;L Right heart catheterization.' C ~ Thrombolysis Transtracheal 02 cannula Venous cutdown Other

NUCLEAR MEDICINE PROCEDURES UL n...o~unll.1 SURGICAL OTHER Bone Bone marriow Kidney Liver

~ J~y J d-oio DATE CIT ClAN As Division Head/Ol Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges and agree the clinician's qualifications are appropriate. We have reviewed supporting documentation submitted for "other" privileges requested by the clinician and have determined that documentation is adequate to verify competency. We find as follows: o Acceptable review with recommendation of appointment to the clinical staff with clinical privileges as requested. o Acceptable with proctoring as documented by the Department Chair and/or Division Head/Ol Liaison. '11 ~ )UJ ({) DIVISION HEAD/OI LIAISON 02/08/2007 Y -= DEPARTMENT CHAIR