Effective Dates: 5/19/2014-5/18/2016
AHP Clinical Privileges Update Form ~Beth Iaeger-Landis Department of UMA Clinic..._, 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 Dotto 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 notconducting an investigation Of proceeding. If prfvileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be mild with thenational Practitioner Databank. ~:...u' h\\'k\oft Date ' \.. fjm,,)lil'_~ -P--t-'t'--'<-'7~s'. t +.L.r..~::"' rac I toner signa ure....i!-. ----------~-- AS,ibeSupervising Pbysician/Ql Liaison/Department Chair/Medlcal Director! Service Center Administrator, we have reviewe{ theabove-named AlIP's level of experience, past performance and quality indicators (if renewing privileges) as related'totequested",ptivileg'es and agreethat the above named AHP's qualifications are appropriate. Since the date of the last, ~upointm,erit,wphave reviewed applicableinformation.from the fouowingsources of quality and utilization data: J&1 Record Review ~ Annual Evaluation.g1 Colitinuing Educ~tjonCi'>nferences Student Evaluation ~ Physica~&MentalHefllthrelated to JobPerformance o Annual Review by Dept. Chair or SeA ~ Risk Management Events/Quality Management Reports for claims ~Pr~scriptivePriYileges (8 hours continuing education documentation required every 2 years) Other. --~~--~--~~----~~~--------~--------~------------------------------------ We find as follows: ~ Acceptable r~view.with recommendation of reappointment with Clinical privileges as requested. o Concetnstlot~d on review with corrective,ion plan in place with recommendation of reappointment with privileges. as requested, but, bject to ar:eview in.",.-...-'. +.-":,,onths...' 1~1~lo1 \.'.... '..,. <te...... -:p::-lr~.i.m!o!' =ary~ ~' ~~e~rv~,.l:-i.s"';'in~. g~p~~~~b::-<!:-~----.ljjli9~'.. \[~Oo/ Andrew Wolfe. M.D. Printed Na.me Mohan Nadakarni.M.D. Printed Name. Joel Schectman, M.D. Printed Name Date Alternate Supervising Physician Signature Date Clinical C e vcsadministrator (for Me employees) ~8~h Ambulatory Services Printed Name Yvonne Me Horney Printed Name ChairlRPC Director Signature (for HSFemployees) Printed Name revised 3/1/2005
AHR Clinical Privileges La.A..~Departmentof ~~~-L~ ~~~~~~~~~ -=~ Update Form UfYJ!t CjlhlC 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 ~B~A~~~0~~ Practitioner's Signature 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 --------'ppointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ Record Review [Yl( Continuing Education Conferences ci Physical & Mental Health related to Job Performance U2f Risk Management Events/Quality Management Reports for claims ~ Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other --------------------------------------------------------------------------------------- _ [0 Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA We find as follows:,= \-l.,;a ~. 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 subje\t to a review in ~ mon;~s.\ \ 0.0/'/(7 ",'mo', ~ '(,~\) ~'V\. D~te, te.~rng Ph y Si 9.".,'. ~1tf7t11-1\ l3at of- f!j1j!.!jjj1l / I" l {/1/ Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervlslnq Physician Signature Printed Name I~ It I D":f- 14.J,~ Date Printed Name Date Chair/RPC Director Signature (for HSF employees) Printed Name revised 3/1/2005
AHP Clinical Privileges Update Form &:fb -::::ro:~lard ~,p"'tm.nt of Urn f4 CJt b. «( _ "[-'-lavereviewed the pn leges previously granted (copy attached) to me and request the followmg changes: w 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. rac ItI ner s Signature As the Supervising Physician/QI LiaisonJDepartment Chairi 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: fgj Record Review lxl Annual Evaluation o Student Evaluation ~. Annual Review by Dept. Chair or SCA 1 Continuing Education Conferences ;61 Physical & Mental Health related to Job Performance ~ Risk Management Events/Quality Management Reports for claims!xl Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other ------------------------------------------------------------------------------------ We find as follows: Date jzl/v/r.s- Date Printed J-MLU>.L Name Printed Name AI i!asjtdjd Date Chair/ Director Signature (for HSF employees) Printed Name revised 1/812003
AHP Clinical Privileges Update Form -"wtt#'''"''''-''--'---->--.;;;~--'-..;..::~:=...;...--=---=\-department of ""'" urn r4 elf f1lv,jjlave reviewed th rivileges previously granted (COP)' attached) to me and request the following changes:!w 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 PhysicianlQI 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ Record Review ~ Annual Evaluation "'?J Continuing Education Conferences D Student Evaluation ~ Physical & Mental Health related to Job Performance BI Annual Review by Dept. Chair or SCA i1j Risk Management Events/Quality Management Reports for claims Prescriptive Privileges (8 hours continuing eduacation 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 acti9~ plan in place with recommendation of reappointment with privileges as requested, but ~bject to a review in ~ ths. ~ ~. " ~([~~ (al"/ P irna. hys;c;an~;gnalu,e Printed ~. J IfL9Gj I&/"~ ~N ate ( Printed Name. (..~/~ttptl rq Prill d a e Date Printed Name -Date Chair/,~lLL EO]2.Ju~ Printed Name -- Director Signature (for HSF employees) Printed Name revised 1/8/2003
Privilege List for Acute Care Nurse Practitioner OI-Apr-03 Name: 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 COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFf BLANK. Date: ACCORDING TO CATEGORY, ENTER A, B, OR C IN THE COLUMN NEXt TO THE LISTED PRIVILEGE: r' 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. ~edical Iedical General General General General ~~'~edical redical Immunization Cardiac Rehab Allergy/Immun Dif Dx & Tx Cardiovascular DifDx & Tx EndocrinelMetabolic Renal Dif Dx & Tx Dif Dx & Tx. RheumatologiclVasc DifDx & Tx Geriatric Cholecystitis Pancreatitis Cirrhosis Infertility Dif Dx & Tx Diabetes Mellitus Renal failure Initial Eval & Mgt Dermatologic Diseases> Dx & Tx Anesthesia Local Tonometry Percutaneous IncisionlDrainage Anoscopy Sigmoidoscopy Skin Testing of Abscesses Arterial Blood Gas Bone Marrow Aspiration Paracentesis Lumbar Puncture Foreign Body Removal> Foreign Bod)' Removal> Subcutaneous Subungual Foreign Body Removal External auditory Wound Mgt. Assess for Functional Integrity Wound Mgt Wound preparation Allergen Immunotherapy Pain Management History and Physical Telephone Triage/Consultation Hospital Rounds Order Medications CNS Infections Health Maintenance & Disease Prevention Chest Tubes- Clamp and/or Remove Neonatal Ped Adol Adult Geriatric (1_ (!.. C C C, C, C (! c <1 c C? ~ e c, e r r: C r: C C (l C. (i c c (J a c ~ ~ e. c. ~ 13 A fj I'.. C. g t=< T-3 1<.. B is r: r C C e. C C. C. C C 6 c a c. r: G Page 1 of 4
-------. rocedure -----!rocedure General General General General General General :eneral General General General General General General General ~'''ocedure rocedure Intradermal Lab Test - Vaginal Lab Test - Throat Skin Testing Cultures Cultures Lab Test - Soft Tissue Site Cultures Lab Test - Blood Cultures Surgical Assist - Draw Tracheostomy Tubes - Remove Transtracheal Aspiration Microscope Eval - Breast Discharge Intermittent Catheterization Tx Urodynarnic Studies - Simple Office Cystornetrics Urodynarnic Studies - Rectal Tube Insertion Urodynamic Studies - Percutaneous EMG fcp Adjust Treatment Protocols Thrombophlebi Ambulatory tis HaIux 02 Saturation Hansel Smear - Nasal Secretions Intracardiac Catheter Removal Omaya Reservoir Typanornetry Epicardial Pacing Wire Removal Pulmonary Artery Catheter removal Dermatomyositis Order -ECG Order - Holter Monitoring Order Order - Labs - Radiographs Order - Urodynamic Studies Authorized Evaluate to Prescribe - ECG Evaluate - EEG Evaluate - Holter Monitoring Evaluate - Labs Central Line Placement & Mgt. Order Exercise Stress Test Evaluate Exercise Stress Test Order Ultrasound Studies Evaluate Ultrasound Studies Adjust Intra-Aortic Balloon Pump Settings Insert Transvenous Pacemaker Remove Transvenous Pacemaker Chest Tubes -Insertion & Mgt Mediastinal Chest Tube Removal Jackson Pratt Drain Removal Pulmonary Artery Catheter Placement Central Venous Line Placement Central Venous Line Rewire Arterial Arterial Arterial Arterial line placement Line Removal Blood Gas Puncture Blood Gas Interpretation Arterial Sheath Removal - >4 in. Venous Sheath Removal AV Fistula Sheath Removal' Needle Biopsy of Liver Intubation & Mechanical Ventilation Extubation Neonatal Ped Adol Adult Geriatric (r C c. e ('. (1 ("I' e... c. r: 6' go C c, r: c c c r I' r: (? c a c r: c (i a (! G C!.- C, e. c (Z... c c c (-~ I' t1 ~ Page 2 of 4
~"lrocedure.'rocedure General General _~eneral Iedical General General General "--'fedical rocedure IV Medications Initiation Adjustment TPN Ordering of Infusions & Fluids - Administration of Infusions Ventriculostomy Catheter Removal Foreign Body Removal - Vagina Adjust Pacemaker Settings Wound Camino Mgt - Debridement Bolt Removal Adjust Cardiac Assist Devices Urticaria Wound Mgt - Dressing Spinal Shock - Mgt Wound Mgt - Closure EMG Biofeedback Arthrocentesis Gynecologic Routine Dif Dx & Tx Thoracentesis CPR Endotracheal Intubation Wound Mgt - Immobilization Breath Hydrogen Test Serum Sickness Foreign Body Removal - Nasal Order- Order Hepatic EEG - Echocardiogram Diseases Dif Dx & Tx Lab Test - Cervical Order Consults Cultures Infectious Disease Dif Dx & Tx Lab Test - Rectal Lab Test - Urethral Cultures Cultures Nutritional Status - Eval & Mgt Osteoarthri tis Lab Test - Dipstick Contraceptive Urinalysis Counseling Peripheral Central Venous Line Placement Chemotherapy - P'OlIVlIntrathecal Cerumen Impaction Removal Ventilator Weaning Mgt Gouty Arthritis Urodynamic Studies - Urodynarnic Catheterization Histamine Provocation Wound Mgt - Removal Urologic Disease - Dif Dx & Tx Impotence - Evaluation & Mgt Surgical Drain Removal Dx, Assessment & Mgt of Sutures/Staples Microscope Eval- Post Coital Cervical Mucous Microscope Eval Vaginal Secretions Microscope Eval - Urine Patient Education Admissions Wound Heme/One (with MD collaboration) Mgt - Electrocoagulation Audiometry Slit Lamp Exam Dif Dx & Tx Neonatal Ped Adol Adult Geriatric c, c C C r: c ~C?:C? \, ~ ~ c: <::. (I (i Ii (i~ s c A A 11 f1 c. c s, ~ r C" c, c c c c. r. C. Co C. C c. c: &e ;;.C.:,-,. C C. c, c.. Q.. c. C (2 c., C. <Z. C C c c G G. C- C r~ 1"- c..- c:- C r: r: c c C- c. C C. Page 3 of 4
CV A Rehab Pulmonary Dif Dx & Tx Spirometry ------\1edical Neurological Dif Dx & Tx. 1edical General Med DifDx & Tx EMG General Evaluate - Echocardiogram Neurodegenerative Disorders Anesthesia Regional Pulmonary Function Testss Psychophysiologic Dif Dx & Tx Electrolyte & Water Balance Rheumatoid Arthritis General Evaluate - Radiographs Pituitary Conditions PAP Smear HIV, AIDS Rheumatic Fever - Acute General Evaluate - Urodynamic Studies Drug Reaction & Overdose OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric (" p Q., c r: r (? G G c- C- C ('~ C~ C' e J (> C. C C- C ~ c, (F.. c (. J J~~~D~)~ DATE _ 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 Alternate Supervising Physician Signature Name Printed /. p-, ' Vj<eft (c/ /f' C 77' Mo ~ tl.a J.h \ klv-fu Alternate SUP~Sing Physician Si nature Name Printed -r: L{~.''U~Y/-::v /'l1.~ Name Printed DATE D t Chair or Svc Center Administrator Page 4 of 4