AHP Clinical Privileges Update Form Rebecca Chamberlain, PNP Department of TCV Surgery /~l have reviewed the privileges previously granted (copy attached) to me and request the following 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. /1 04= Q~ ~ 1Nf' Date practitiour's Signature I As the Supervising Physician/QI 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: ''''--~''-"""T"----------------------------""""""?-------------------' ~ Record Review [1' Continuing Education Conferences 0 GJ Physical & Mental Health related to Job Performance 0 [6" Risk Management Events/Quality Management Reports for claims Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA 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. e action plan in place with recommendation of reappolntrnent with privileges as requested, but sub'i! ew~.r.ejj~~n months. James Gangemi. M.D. Printed Name Alternate Su ervising Physician Signature 4-Cnt:iir Irving Kron. M.D. Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date Clinical Care Svcs Administrator (for MCemployees) Printed Name Irving Krong, M.D., Chair Date. Chair/RPC Director Signature (for HSF employees) Printed Name revised 3/1/2005
AHP Clinical Privileges Update Form Rebecca Chamberlain, PNP Department of TCV Surgery 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): I 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 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 ~ontinuing Education Conferences g' Physical & Mental Health related to Job Performance o Risk Management Events/Quality Management Reports for claims o 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:./ 8' Acceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with correctiv as requested, but subject t a view ir9! ~UA\9~ Date' q~,:\~ ~\U\O~ Ddte ' taction plan in place with recommendation of reappointment with privileges months. ~~~~~~ Physician Signature AI ervising Physician Signature Benjamin Peeler, M.D. Printed Name Irving Kron, M.D. Printed Name James Gangemi, M.D. Printed Name Date Alternate Supervising Physician Signature Printed Name Date Printed Name Irving Kronl, M.D.. Chair Chair/RPC edical Director Signature (for HSF employees) Printed Name revised 3/1/2005
Atl1' Llmlcal Yrivlleges Update.Form A& ectlci}()/n~ (CL{tJPepartment of--2~~~~~\--- _ 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): do ~ { J.-.-~. _ 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 p,a'tit;one~--l{m-'v/ ---------- 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: rp Record Review ~ Annual Evaluation ~ Continuing Education Conferences!Physical & Mental Health related to Job Performance,. Risk Management Events/Quality Management Reports for claims Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other o Student Evaluation o Annual Review by Dept. Chair or SeA _ We find as follows: ~ Acceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with correcti.e action plan in place with recommendation of reappointment with privileges as requested, but subject to view i' months. Ben Peeler, MD Printed Name lja:ll~1 Date Paul Matherne, MD Printed Name _,Scott Lime MD Printed Name Date Alternate Supervising Physician Signature Printed Name Date 'd't/ Q 1 Date Clinical Car cs Administrator (for Me employees) Printed Name Trvjng ikr~o~n~m~d~ _ Chair/RPC Me ical Director Signature (for HSFemployees) Printed Name revised 3/1/2005
.~ ~WaJ..h Department of -'--- --f-'~ ;~=-------- I have reviewed the privileges previously granted (copy attached) to me and request the fol New Privileges to be Added (please indicate category level and type of experience):. g 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 reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. 2& A/uY O\; yej~a~t1'\;1 / Date practitio~er's Signature As the Supervising Physician/QI LiaisonlDepartment Chair/ Directorl Service Center Administrator, we have reviewed the above-named AEP'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 ofthe last appointment, we have reviewed applicable information from the following sources of quality and utilization data: if Record Review 0 Annual Evaluation Q/ Continuing Education Conferences 0.,Student Evaluation Q'" Physical & Mental Health related to Job Performance B" Annual Review by Dept. Chair or SCA 8' RiskManagement Events/Quality Management Reports for claims. [Q/Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: ~ceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with c as requested, but subject to a r i />-/r 1100 Dale I?/;;O/OC Date t \ 'l--\?a)i~ Date -=-:---:-I---Tr-"~~-:-:--~-:---- AI r: gnature n plan in place with recommendation of reappointment with privileges months.. ame Alternate Supervising Physician Signature Printed Name V-o.uL }l tl& H...!:.,;!J:>_ Printed Name I S\Q* \;.~ I k]) Date Alternate Supervising Physician Signature Printed Name Date loft:(6c Printed Name Printed Na revised3/1/2005
privilege List for: Pediatric Nurse Practitioner J J -lul-06 Name: 3 brum $. tho liid,b-iv bl'16_ 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 wmcn YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRrvILEGE 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. ~---. ~ Pulmonary Function Tests Percutaneous Sigmoidoscopy Colonoscopy Endoscopy- Arthrocentesis Bone Marrow CPR Endotracheal Circumcision Biopsy/RemovaJ Skin Testing - Assist Assist Hemodialysis Peritoneal dialysis Congenital Hypertension Rheumatic GI Disease DifDx Heme/One Hemophilia Leukemia Hepatic Aspiration Intubation - Skin Lesion Heart Disease Heart Disease & Tx Dif Dx & Tx Diseases Dif Dx & Tx Premature Disorders Dx & Tx Premie Growth & Development Neurological Die Dx & Tx CNS Infections Psychophysiologic Renal Die Dx & Tx Die Dx & Tx Electrolyte & Water Balance Urologic Croup, Disease - Dif Dx & Tx epiglottitis Cystic fibrosis Pulmonary Ped Developmental Attention Cerebral Die Dx & Tx Dif Dx & Tx Deficit Disabilities Palsy Head & Spinal Cord Injury Ped Learning & language disabilities Ped Mental retardation EndocrinelMetabolic Diabetes Mellitus Dif Dx & Tx Neonatal Ped Adol Adult Geriatric c c. c.. C c, c e, c. c c.. c. c C c. c c. c C; C C C. C. C. c. r= c c c. c.. C Co c C. c. c. r c, t.. c- Page 1 of 3
Medic~1 Meoical General General General General General General General General General General General General Pituitary Malabsorption General Immunization AllergylImmun Arthritis Cardiovascular Infectious Conditions Peds Dif Dx & Tx Birth Defects Eval Newborn Newborn Dif Dx & Tx Dif Dx & Tx Disease Dif Dx & Tx Dif Dx & Tx screening Adjustment Problems Ped Behavioral Problems Cognitive Dialysis Mgt Rehab RheumatologicJVasc HIV, AIDS Immunodeficiency Dif Dx & Tx Wound Mgt - Assess for Functional Wound Mgt - Wound Wound Mgt - Debridement Wound Mgt Closure Wound Mgt - Dressing Wound Allergen preparation Mgt Immobilization Immunotherapy Wound Mgt Removal of Sutures/Staples Prenatal Counseling Pain Management History and Physical Dx, Assessment & Mgt Telephone Triage/Consultation Hospital Admissions Order Order. Order v Order Order Order Order Rounds Labs ECG (with MD collaboration) Echocardiogram - EEG Radiographs Consults Medications Mickey Gastrostomy Buttons - Changing Neonatal PEG Placement- Resuscitation Assist Integrity PH Probe- Insertion & Verification of Placement Rectal Manometry - Assist Umbilical Catheter - Arterial or Venous TPN Ordering.Contraceptive Counseling Health Maintenance & Disease Prevention Nutritional Status - Eval & Mgt Cardiac Care - Pre & Post Op Ventilator Weaning Mgt Chemotherapy - POlIVlIntrathecal Chest Tubes - Clamp and/or Remove Intradermal Lab Test - Dipstick Lab Test - Vaginal Lab Test - Cervical Skin Testing Urinalysis Cultures Cultures...... ~...-. _w 1"~V n.u.. l.,,,.. C c c r. C C C. C- c. c. c C t. C. <. c. c. t c.. C. t.. C. C. c C C C c. c. C c C. e e c c. c. e, c. C C c G e, C.- c c. (.. C t C. C t: to C. C C, C C Co C C C. C. C c C. e C. C. c C. C. c. c.. v t.. C. C. e, C. C. c. C c. c c.. c. c. C. C -L. C C. C. (. c c.. c. c. c.. Page 2 of 3
Ptoc'ed1<lre Lab Test - Urethral Cultures P'L'ox:edure Lab Test - Rectal Cultures Lab Test - Throat Cultures Lab Test - Soft Tissue Site Cultures Lab Test - Blood Cultures - Draw Lumbar Puncture Surgical Assist Surgical Drain Removal Tracheostomy Tubes - Remove Wound Mgt - Electrocoagulation Hyperbilirubinemia Ped Emotional Disorders Cerumen Impaction Removal Anesthesia Local Anesthesia Regional General Authorized to Prescribe General Evaluate - ECG General Evaluate - Echocardiogram General Evaluate - EEG General Evaluate - Labs General Evaluate - Radiographs OTHER PRIVILEGES c. c.. Co c... c.. C. C c. e, c c, c. C c, Co C. c.. C- c. c. c. l C. c. c c. C. C. L C (. c c::. I l'/m'vc C!"-'W'Ke. e.cc,o, S. ch Name Printed As the Collaborating Physician and Department Chai ervice Center Administrator, we have reviewed the abovenamed practitioner's level of experience, past perfonnanc nd quality indicators (if renewing privileges) as related to requested privileges and agree that the above ed pra itioners qualifications are appropriate. DATE 1-7Ct- 0 " 7 -"2 ~ -0 y DATE Name Printed DATE ternate Supervising Physician Signa ure DATE ~ Alternate Supervising Physician Signature Name Printed DATE Dept Chalr& Alt Supv Physician Signature.r.> Name Printed Page 3 of 3
Addendum to the Pediatric Nurse Practitioners Privilege Form The National Pediatric Nurse Practitioners 2002 states the following: Position Statement on Age Parameter for PNP Practice, Many pediatric oncology NPs are trained and certified as pediatric nurse practitioners (PNPs). Although the scope of practice for PNPs is generally limited to patients within the pediatric age range (birth to 21 years), the National Association of Pediatric Nurses Practitioners (NAPNAP) provides guidance regarding circumstances when the scope ofpnp practice may extend beyond the pediatric age range, as follows: "There are special situations in which it is appropriate for the PNP or other pediatric healthcare providers to care for an individual older than age 21 years until appropriate transition to adult healthcare is successful. There is a growing population of adolescents and young adults with special healthcare needs, chronic conditions, and disabilities who need transition care from pediatric to adult healthcare settings. These adolescents and young adults face unique challenges in accessing adult health care providers who can provide adequate primary and specialized healthcare services. 23, 24 Pediatric healthcare providers have an extensive knowledge base regarding developmental issues and a unique awareness of the concerns pertaining to adolescent and young adult healthcare provider transitions and are qualified to assist these patients during the transition phase. 25 Establishing exclusive upper age limits to PNPs' practice may create a significant barrier for PNPs and may limit access to healthcare for this population. In summary, the PNP is highly qualified to provide care to individuals from birth to age 21 years, and in special circumstances beyond age 21 years. NAPNAP firmly supports the scope of practice for PNPs to be inclusive of newborns, infants, children, adolescents, and young adults. NAPNAP additionally supports the PNP's role as a provider of health care for individuals older than 21 years with unique needs and for young adults during the transition to adult health care. " National Association of Pediatric Nurse Practitioners Position Statement on Age Parameters for PNP Practice, 2002 (2 out- 01 Date Date I Date Signature of Alternate Supervising Physician Date Signature of Alternate Supervising Physician Date Signature of Date Chair! Admini trator Signature June 2009