" AHP Clinical Privileges Update Form Robert Davis Department of Neurology 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 e hile you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be repor d as voluntarily relinquished you will be notified and receive a copy of the port to be filed with the National Practitioner Databank. 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 ~pointment, we have reviewed applicable information from the following sources of quality and utilization data: IYl" Record Review ~ Continuing Education Conferences [3' Physical & Mental Health related to Job Performance ~ Annual Evalua.tion o /Student Evaluation E1 Annual Review by Dept. Chair or SCA 0' 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: ~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 r~"'2j int- months. jl l1 1\:) );.; lr~n't~ Frederick Wooten, M.D. ~ Primary Su ervising Physici n Signature Printed Name!.~'1-1 24(0 te Madal;ne B. Harr;son. M.D. Printed Name ~J. b/i> Daniel Larriviere, M.D. Date Printed Name ~~ Date Alternate Supervising Physician Signature Printed Name z/1j!o Karen C. Johnston, M.D. Date Printed Name revised 3/1/2005 Da~ Printed Name
". AHP Clinical Privileges Update Form &/ovlf 6avc-s Department of Altlut()(~-LlL~. - have reviewed the privileges previously granted (copy attached) to me and requ~;z:;ollowldg 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 tiled with the National Practitioner Databank. 1 As the Supervising PhysicianlQI Liaison/Department Chair/ Director/ Service Center Admiriistrator, 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 ~ Continuing Education Conferences 0 Student Evaluation ~ Physical &.Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA ~/Risk Management Events/Quality Management Reports for claims ~ Prescriptive Privileges (8 hours continuing education 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 action plan in place with recommendation of reappointment with privileges. as requested, but subject to are in months. l/;{t Lo «-=-:---r<-::--;''''f--:----=---='-:--f-=-~oat ~"'~!:'ng p~ Signatu," \![.,(( D~' }1~\A~Q.:...:"-'~..Ao..~,-- _ Date Alternate SURervising Physician Signature Printed A~~ Printed Name Name ~(S""- Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date OJJlttLt7t. Printed Name J(~~TI~~ Date Printed Name revised 3/1/2005
.> " AHP Clinical Privileges Update Form &hmf 6a.V(~ Departmentof AlWAO(OJi-=fJ _ ---'lave reviewed the privileges previously granted (copy attached) to me and request J:;ollowing 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. ----- As the Supervising Physician/Qf Liaison/Department 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 ~pointment, we have reviewed applicable information from the following sources of quality and utilization data: Record Review ~ Annual Evaluation ~ Continuing Education Conferences 0 Student Evaluation 0' Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA ~Risk Management Events/Quality Management Reports for claims ~ Prescriptive Other Privileges (8 hours continuing education documentation required every 2 years) _ We find as follows: ~ Acceptable review with recommendation of reappointment with clinical privileges as requested. Da Signature Printed Name Avdk:t' ~{S""-- Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date Printed Name ;:~tn~~ Printed Name revised 3/1/2005
AHP Clinical Privileges Update Form ----!~~()=_bvrl:=~=--~.:..:=..:...:v~~_=0= "Department of ---''---=:...;:..-!..C---"?'~+- _ "-~,I have reviewed the privileges previously granted (copy attached) to me and request New Privileges to be Added (please indicate category level and type of experience): ~ C-:t:.. <! c1. -?C v / 7 following changes: 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 report as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Da tj tit 0 r's As the Supervising PhysicianlQI LiaisoniDepartment 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 iyv Continuing Education Conferences IU1, Physical & Mental Health related to Job Performance err. Risk Management Events/Quality Management Reports for claims [l( Annual Evaluation o Student Evaluation 0'" Annual Review by Dept. Chair or SCA [i' 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 ~equested, but SUbject>~areview in months. _I ~~\tuy if"!;f2j / -'- C..lllrk:~ u.9~:l... \ Dat~ ~rimary up, ising Physician ignature Printed Name,/., ~~(,,1- ( i /l'k~ il!forc/sc- f,i. fr~_ ~.d ~/Dat i / Alternate Printed Name ~ / ;;;A/o"] Joe:.l l ('v~ Name -u---- 1/ " -::J-:~-:--:-:-:>_- _..o::b'-c_~-vt_~_~_- D e Printed Name Clinical Care»n Ad. Printed Name,,0~!AJ64j -, ~!tltlu ~ ~ Chair/RPC DirectiSignature (for HSFemployees) Printed Name.' revised 3/1/2005
. ~ AHP Clinical Privileges Update Form ~&_u=-o:2..f::w,=------,-~_~i)~i~=- Department of--j.-..:::t=l~~..!.u~~:::...- --,- _ I have reviewed the privileges previously granted (copy attached) to me and reques /~Tew Privileges to be Added (please indicate category level and type of experience): e following changes: Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless thib'o/done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be r~or;:ted 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 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~... Record Review [3(' Annual Evaluation ca' Continuing Education Conferences ~tudent Evaluation WPhysical & Mental Health related to Job Performance ca/annual Review by Dept. Chair or SCA W Risk Management Events/Quality Management Reports for claims ~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 a~tjon plan in place with recommendation of reappointment with privileges ~s requested, I but subject to a r~vrew}rv'" / i months",j l' r) / i,(i- >.Jf //1 l;,rl.//--'-/ r: ~ cl,l ute /(j ~Jk'-" v Y (A.> If\. 01.1: Ukrn D te'. Primary Supe i ising Physician Signature' print.ed Name. z b ob \...1'(, _ f ~ e&l.:. L 4.n=jJ5~ D,te, Alternate upe~ising PhYS~ignature ~a~e _ c>&~/i)(,. I. ji.{ ~...A. \CVJ~-.a/, Phy ici n Sig ature ~. me ~ ;;{ Z: 6 -> <l2..., il a1i1'1k;t/ ate Printed Name ~ Date I LIZ ItJD Oate ' # "..~ //. Clinical Care Svcs A in!.s. 'tator-'(foric,..('j' I,.:/,,/ :: /' employees) ~/ I, /,Iv ~.,-. '" ChairiRPC Director Signa}lire (for HSF employees) Printed Name Printed Name revised3/1/2005
AHP Clinical Privileges Update Form Departmentof -+~-=~~~~~~~ _ I have reviewed the privileges previously granted (copy attached) to me a request the following changes: New Privileges to be Added (please indicate category level and type of expe ience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquish unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privilege e to be reported as voluntarily relinquished you will be notified and receive a 0PY of th eport to be filed with the National Practitione tabank. As the Supervising Physician!QI 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 ~~ointment, we have reviewed applicable information from the following sources of quality and utilization data: o Record Review c1" Continuing Education Conferences [j Physical & Mental Health related to Job Performance [2f Risk Management Events/Quality Management Reports for claims ~ Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other _ We find as follows: ~ [2( 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()r)e~sted' but subject to a revi in ~nths. ~ u. ~ GFW;;;()k. o te ising Physician Signature Printed Name Date ~CO( Date 411 frm:i / rj r i? j@u-""u...::<:d::o.</c-:j"-- _ Printed Name.-- (,-:- J 11<.. \ vft\ (V'U.~'"1."- Printed Name r~-"----- TzfvhELME&Uff~ Printed Name k Printed Namr Gr(JOo~. Printed Name
AHP Clinical Privileges Update Form Department of ~~_e.vvt o_(_o-\:-......:::::r- }-J,lave reviewed the privileges previously granted (copy attached) to me an request the following changes: N 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 ss this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges ar to e reported as voluntarily relinquished you will be notified and receive a copy f the report to be tiled with the National Practitioner Da b k, As the Supervising Physician!QI Liaison/Department 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 c, Continumg Education Conferences...:J Physical & Mental Health related to Job Performance []' Risk Management Events/Quality Management Reports for claims Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SeA u1 Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other _ We find as follows: rz( 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 revlew-ln onths. ) I I..-r;:; ~ 13c.., -" - 7' vt ' ~ batd Primary Supervi"ng Physician S.'gnature r...( "o( 00,! ~ ')-/~I ()'t o~ v(~'f Printed Name Date I ". IOJ!DY bate I Printed Name ~r WO,)*~ Printed Name revised 1/8/2003
Privilege List for: Family Nurse Practitioner 08-Jul-03 '~Name: k i4&? fzj4~/1&;...---- Date: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULA Y 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 RE LEFT BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE 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 andlor consultation with the physician. ~'1edical ~\1edical Aedical Congenital Heart Disease Rheumatic Heart Disease GI Disease Dif Dx & Tx Premature Disorders Dx & Tx Premie Growth & Development Neurological Dif Dx & Tx CNS Infections Psychophysiologic DifDx & Tx Renal Dif Dx & Tx Electrolyte & Water Balance Croup, epiglottitis Cystic fibrosis Pulmonary Dif Dx & Tx Pre & Post Op Cardiac Care Attention Deficit Disabilities Cerebral Palsy Head & Spinal Cord Injury Ped Learning & language disabilities Ped Mental retardation Pituitary Conditions Malabsorption General Peds Dif Dx & Tx Immunization Osteoarthri tis Rheumatoid Arthritis Rheumatic Fever. Acute Cardiac Rehab Neurodegenerative Disorders Endocrine!Metabolic DifDx & Tx. General Med Dif Dx & Tx Allergy/Irnmun Dif Dx & Tx. Arthritis Cardiovascular Dif Dx & Tx Birth Defects Eval Newborn Dif Dx & Tx Newborn screening Adjustment Problems Ped Behavioral Problems Cognitive Rehab Dialysis Mgt Neonatal Ped Adol Adult Geriatric C2 c:::. G C- L C- c: c. c: C- C (" I'"., C G L- C' c ~ r: C c: c: c. /J. /f A -: C- r: Page 1 of 5
~ ~ 'rocedure /"~'l"ocedure ~rocedure RheumatologidVasc HIV,AIDS Immunodeficiency Health Geriatric Cholecystitis Pancreatitis Cirrhosis Maintenance Dif Dx & Tx Dif Dx & Tx Hepatic Diseases Dif Dx & Tx Gynecologic Routine DifDx & Tx Infertility Initial Eval & Mgt Sexual Infectious Diabetes Fractures Counseling Disease Dif Dx & Tx Mellitus & Dislocations Pediatric Emotional Disorders Dermatologic Diseases> Dx & Tx Drug Reaction CVA Rehab Anesthesia Local Anesthesia Regional & Overdose Pulmonary Function Testss EMG Audiometry Tonometry Slit Lamp Spirometry Percutaneous Exam PAP Smear Fetal Monitoring Incision/Drainage Skin Laceration Anoscopy Sigmoidoscopy EMG Biofeedback Arthrocentesis Arterial Bone Marrow Paracentesis Thoracentesis CPR Endotracheal Circumcision Blood Gas Skin Testing of Abscesses Repair Aspiration Intubation Norplant Insertion & Removal Breath Hydrogen Test Cryotherapy Lumbar Puncture Foreign Body Removal - Subcutaneous Foreign Body Removal - Subungual Foreign Body Removal - External auditory Foreign Body Removal> Vagina Wound Mgt- Assess for Functional Integrity Pulmonary Artery Catheter Manipulation Wound Mgt - Wound preparation Wound Mgt - Debridement Wound Mgt - Closure Wound Mgt Dressing Wound Mgt - Immobilization Neonatal Ped Adol Adult Geriatric L- e: C-? -: L -: r": r C- c. -- c- a 0 L1 /.),.q Ll L c. I C I Page 2 of 5
~, General General General General General General General General General General General General General General, ------ ' '~""rocedure _'rocedure Nail Avulsion IUD Insertion & Removal Pessary Insertion & Removal Allergen Immunotherapy Histamine Provocation Wound Mgt - Removal of Sutures/Staples Prenatal Counseling Impotence - Evaluation & Mgt Pain Management History and Physical Dx, Assessment Telephone & Mgt Triage/Consultation Hospital Rounds Admissions (with MD collaboration) Order - Labs Order - Urodynamic Studies Order- Order ECG - Echocardiogram Order - Holter Monitoring Order Order > Order Order - EEG Radiographs Consults Medications Nutritional Status - Eval & Mgt Peripheral Central Venous Line Placement Contraceptive Counseling Health Maintenance & Disease Prevention Cerumen Impaction Removal Ventilator Weaning Mgt Chemotherapy Intradermal Lab Test - Dipstick - POlIVlIntrathecal Skin Testing Lab Test - Cervical Lab Test - Urethral Lab Test - Rectal Lab Test - Throat Urinalysis Cultures Cultures Cultures Cultures Lab Test - Soft Tissue Site Cultures Lab Test - Blood Cultures Surgical Assist Surgical Drain Removal - Draw Tracheostomy Tubes - Remove Transtracheal Wound Aspiration Mgt - Electrocoagulation OB - Routine Prenatal & Postpart Eval & Mgt on - Intermed. Risk Prenatal & Postpart Eval & Mgt on - High Risk Prenatal & Postpart Eval & Mgt Cardiac Arrest- Assist Colposcopy - Cervical Biopsy/ECC Condyloma Microscope Tx's Eval - Urine Microscope Eval- Post Coital Cervical Mucous Microscope Eval- Breast Discharge Microscope Eval - Amniotic Fluid Intermittent Catheterization Tx Ultrasound. Fetal Ltd - Fetal Presentation Ultrasound - Fetal Ltd - Fetal Cardiac Activity Ultrasound- Fetal Ltd - Dating 1st Trimester Ultrasound - Fetal Ltd > AFI Neonatal Ped Adol Adult Geriatric c:::.. c... L L. C '-' /" /' L '? c. e I" C- c- 4 ~.'LJ a d3' fl /" ~ c::... --,.-::. C- c-»: c- G -: C- c:- /.. L L C- c: r e- c, c...- -: C 0 e. r r: L- C- C-- C r: C- C. c... C C C r: R A- /.f- Page 3 of 5
,'----- " "---. "')rocedure General General General General General General General General Urodynamic Studies - Simple Office Cystornetrics Urodynamic Studies - Urodynamic Catheterization Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Percutaneous EMG Gouty Arthritis ICP Adjust Treatment Protocols Heme/One Hyperbilirubinemia Spinal Dif Dx & Tx Shock - Mgt Thromhophlebi Urologic Urticaria tis Disease - Dif Dx & Tx Adjust Pacemaker Settings Adjust Cardiac Assist Devices Ambulatory Halux 02 Saturation Camino Bolt Removal Hansel Smear - Nasal Secretions Intracardiac Catheter Removal Ornaya Reservoir TPN Ordering Typanornetry Ventricular Catheter Removal Conscious Diaphragm Sedation Fitting Biopsy - Endometrial Chest Tubes - Clamp and/or Remove Epicardial Pacing Wire Removal Doppler Monitoring of Fetus Ortho s - Nasal Ortho s - Ribs - Stable Chest Ortho s - Shoulder Dislocation Ortho s - Clavicle Ortho s - Upper Extremities Ortho s - Lower Extremities Pulmonary Artery Catheter removal Biopsy/Removal Biopsy - Vulvar - Skin Lesion Foreign Body Removal - Nasal Lab Test - Vaginal Cultures Serum Sickness Microscope Eval- Vaginal Secretions Authorized to Prescribe Evaluate - ECG Evaluate- Echocardiogram Evaluate - EEG Evaluate - Holter Monitoring Evaluate Evaluate - Labs - Radiographs Evaluate - Urodynamic Studies Dermatomyositis Nephrotic Disease Dif Dx & Tx Neonatal Ped Adol Adult Geriatric r: ~ c:;.- -: r:.zz- C-»: -: /'»: r ez: e: a: r: C- r: Page 4 of 5
OTHERPRIVll..EGES Neonatal Ped Adol Adult Geriatric 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 DATE DATE Alternat Alternate G. Frederick Wooten, MD Name Printed el M. me Printed Trugrnan, MD Madaline B. Harrison HD Name Printed DATE Alternate Supervising Physician Signature Name Printed DATE Dept Chair or Svc Center Administrator Name Printed Page 5 of 5