AHP Clinical Privileges Update Form Gavin MacCleery, PA - e... Department of Neurosurgery /-----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 Databa Date 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: o )v1edical Record Review Annual Evaluation ~ Continuing Education Conferences 0 Student Evaluation CiV'Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA o 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 ;5 r:q,ested, but s bject to a rev.ew in months. q ('1-'110 OJ. Date Mark Shaffrey. M.D. Printed Name Gregory Helm. M.D. Printed Name Date j/~/!bj Datel ij:,k Date I ~ W. Jeffrey Elias. M.D. Printed Name Christopher Shaffrey. M.D. Printed Name Printed Name Mark. E. Shaffrey. M.D. Printed Name revised 3/1/2005
, Gavin MacCleery, PA Privilege Update - Additional Supervising Physicians Date Neal Kassell. M.D. Printed Name Aaron Dumont, M.D. Printed Name Ladislau Steiner. M.D. Printed Name 'f-cl -1 Date John Jane. Jr., M.D. Printed Name Jason Sheehan. M.D. Printed Name Date ~tv\l~ Date Alternate Supervising Physician Signature Edward Oldfield. M.D. Printed Name Justin Smith, M.D. Printed Name 7~ J%~s.."W,,~,, ~~
Privilege List for: Physician's Assistant 27-Feb-08 Name: _ira.'jc ~q-_ C-.~_~_ Date: _ d-f;j J-/d2-- PLEASE MARK AS REQUESTED Oi'lL Y THOSE AREAS ~E 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 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 and/or consultation with the physician.,~. General,~ General :;eneral General General General General Anesthesia Local Arterial line placement Bronchoscopy Cath Swan Ganz catheter placement Catheter - IV Peripheral - Placement & Mgt Chest Tubes - Insertion & Mgt ECG Administration Feeding tube Placement Halo Vest - Adjustment Halo Vest - Pin Care Halo Vest - Placement IABP - Placement & Management Injections - Intradermal Injections - Intramuscular Injections - Intravenous Insertion, Catheter - Bladder Intradermal Skin Testing Intubate IV Medications & Fluids - Administration Lumbar Puncture Mini Tracheostomy NG Tube Insertion Place trans-venous pacer Re-open Explore Chest Surgery Assist ~ Ist & 2nd Assisting Surgery Assist - Harvesting Vein Surgery Assist.. Position & Prep Suturing - Major Suturing - Minor Thoracentesis Venipuncture Venous cutdown Wound Mgt - Debridement Wound Mgt - Removal of Sutures/Staples Evaluate - ECG Evaluate - Echocardiogram Evaluate - EEG Evaluate - Holter Monitoring Evaluate - Labs Evaluate - Radiographs History and Physical Neonatal Ped Adol Adult Geriatric C-- A c, L L i I A 1'1:) p.. B 0 1) C> (3 r?> JS I fr B t3 ~ B k 0 c...- L C- It- C e e {) ( C c C C-- i ~ C3 B B.B I ' () C c, C- c. c ~ ~ ~ B B I J.- B R 6 B., C. C o. <- I (- c, J C L, r c (. e, ~-i ob C ( L C ~ L- L- e! c. A R ~ ~ 'C B L C-, L C, k c., c.. c. c,! ~ It> 6 '0 \3 P- C C- L I J:=' ~ ~ (3 B fr A- I!-- A c. c. G-- c- "\ ~ ~ ~ ~ C-- c, I C- c- '> C- c. c. L- I C- C L C I k e e c. c, -c --C' c..-i C- c- i I A- 1\ b R 8 It 6 r: C- C..- C- G C r: C-- (. c C c L c, C. C I c e, C- C- C C- c. c c C- C c- c L e. e. c. L C. C- C. G L L C c. G I I
=>. General General General General General General General General General General General General OTHER PRIVILEGES Hospital Rounds Order- Diet Order-ECG Order - Echocarrdiogram Order- EEG Order- EMG Order - Holter Monitoring Order - Labs Order - Radiographs Order Consults, Order Medications Patient Education Neonatal Ped Adol Adult Geriatric C C L C. c., C c C L r c, ( C r C L! c. r c. c., c. r c. c. L I r c C c- c I c, c c- I L L c, e, c. C-, c.! C! It ( c, c-- c. L c c. C C- I ~~{~---s------------- 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 abo na ed practitioners qualifications are appropriate. DATE -~ DATE DATE Name Printed DATE ~\e<-~~ ~.e~'i(,r~",~ 1'''4(',:.:'-<6. «<; ~c\."'o-\-~~
3\\~O~ \ ' Date ising Physician Signature Name Printed Alternate Supervising Physician Signature Name Printed ~ Date. ~9 ------------rr------------------------~~~~~~~ g Physician Signature 3-\7- ~.? Date ~\Lq\O~ Date \ Alternate Supervising Physician Signature 4 Alternate Supervising Physician Signature Name Printed Name Printed