Clinical Privileges Update Form Secondal'Y Appointnlent Jamieson Bourque Department of Radiology I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional h'aiuing necessary to pedol'm new plivileges requested. (please inciu(1e supporting documentation to verify competency): New Privileges to be Added (1)lease indicate category level am1 type of experience): -_......... --_..._-_...---..._-_.. _....._-.._--...---.._--_.. --....---... --..-.. ---...--..._-_........ Cnrrent Privileges not to be Renewed:*..---..--... --.........-........!*Prlvlleges 1I0t renewed are not,'eported as bel;lg voluntarily relinquished unless tltls is done while you at"e under Investigation; 'or, in retul'1i Cor not conducting an illvesligatioll or proceeding. If privileges are to be reported as voluntarily relinquished you Iwill be notified Aud receive a copy onlle report to be filed with the National Practitioner Databank. ~ -_.. " ".' ~ -... '3 /d-'-\.i \\.--.... CL~~~"-V-~-...-....-._--... DATE As the Division Head/QI Liaison and Department Chair/Medical DIt'ector, we have reviewed tile abovenamed clinician's level of experience. past performance and quality indicators (ifrenewing privileges) as related to requested privileges and agree tllat the above named clinician's qualifications are appropt'iate. Since the date of the last appointment, we have t'eviewed applicable information from the following sources of quality and u. tioll data: We fin Acceptable 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: -..,....._-...:;,..'---"... D~T-E1+ D~L '_ArlS.+0---b'-/"-'''''- DATE DEPARTMENT CHA R."I~d 31111006
". UVA Medical Center, UVA Transitional Care Hospital & UVA Health South Rehabilitation Hospital /----" REQUEST FOR CLINICAL PRMLEGES Department of Radiology ~o..w\~e.scn ~ OV''l V~ Medical School and Year of Graduation Ov ke... FellowshipIPost.Residency Training Location and Years, to\.+-u""v\q. \ M...J..; e i r\~ Board Certification in Year of Certification Admitting Privileges? lti Yes DNo Transitional Care Hospital?D Yes felno 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 NOTREGUl,ARLYPRACTICE SHOULD BE LEFT Category B Category C The apphcant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties. The applicant will independently manage patients. The applicant would be expected to request consu,ltation only occasionally. OOIumn. Type 1 Type 2 Limited Experience without formalfrairiirlg ExtenSive Experience,- hc~hffifi~~w------m~~~~~~~~~~~~--.-~1 INTERVENTIONAL fv"\l.jivl.vu
Category A Category B Category C The applicant will occasionally perform or assist in the performance of the procedure. Consultation will be sought in the event of anticipated or actual difficu!ti$s, The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. According to type, Type 2 Formal Training Program Limited Experience without formal training Type 3 Extensive Experience -without formal training - ----- - ------------~-----~-~--- ------ ---- i PRIVILEGES REQUESTED AREAS CATEGORY TYPE i REQUESTED EXPERIENCE I (A, BorC) (1,20r3) -- ----- - -- --- - -- - - - - --- - - - ----- ~-- - - ~- ~ ~ ~-- -~------ ~-~------- Conscious sedation CT Cyst/abscess drainage Diagnostic contrast examinations Fine needle aspiration and biopsy Fluoroscopy Foreign body extraction Luminal stent i.nsertion MRJ Percutaneous tube placement Plain film.f~diography.. Stricture dilatation ~...-..-..."--...,. 1-..._ _.. _........_ _ _...._ 1 --... _ _......... _...--.._......-........._..._... Ultrason9W8Phy...,j...~...~ -,~~.~...-...--~,..-- -..--...-..._.-_....._..._..._..."'. Genitourihaty Antegrade urography...... ~..r......................._...--....0..._...--... Conscious sedation CT Cystography Fallopian tube recanalization Hysterosalpingography Intravenous urography MRI I.........,......... 1...... _".....,......................u............ i--..............~......_-..._......_..._...
cont1d Percutaneous interventional GU procedures PlaihfitmradiOgraPhy Retr()$lra~epY~~r~Pf1Y RetrOgi'adeU:rethtOgfaphy Ultrasound Consciou$$edation Fetal ultrasonography Transabdominal RADIOLOGY
NUCLEAR IMAGING \ PEDIATRIC RADIOLOGY \ Feeding tube placement Fonaign body MRI DATE
L ----~~---- ----~-- ------~---------~---~----------- --~--~--~---~-----~~-------~-----:J Page As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience, past performance and quality indi~tor~ (if renewing privileges) as related to requested privileges and agree that clinician's quali'ncatjons E,lregppropriate. The following indicators have been reviewed for reappointment. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality data: PhYSician's Health & Mental Status Inpatient Attending Performance Morbidity and Mortality Reports Blood Usage Reports Drug Usage Reports InfectionReports Invasive/Non-lnvasive Procedures Medical Records Documentation Patient/Family Satisfaction Sentinel Events/Risk Management Reports Consultation Attending Performance Outpatient Clinical Practice Peer Review of CHnical Performance Other:. We find as follows: Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested. Concerns noted on review with corrective action p~an in place with recommen dation of reappointment to the clinical staff with privileges as requested, but subject to 8.review in _ months. x DATE 7/u/!O, DATE DEPARTMENT CHAIR clin.,pri.rad R:06/21/10