Clinical Privileges Update Form Michael Salerno Department of Medicine I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type ofexperience):..._-_... _---- Current Privileges not to be Renewed:* -----_..._-_... _--..._-_..._-_..._-_..._-_..._-,""","",",-" l"'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. Ifprivileges 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 Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician'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: We r~~ follows: YJ ~cceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested [J DATE DATE 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: P 3 Lawrence Gimple. MD --- ~Division Chief/Quality Liaison RE Mitchell Rosner. MD Interim Department Chair Revised 3I11l006
.. U..NIVERsITỊ T ~_VIRGINIA HEALTH SvsT:EM r--. M \ C""Q,Q..'\ s~\u"o Name Ul\i~~~ REQUEST FOR CLINICAL PRIVILEGES Department of Medicine 1..00'"3 Board Certiflcation(s) In. Admitting Prhffleges? PLEASE MARK AS REQUESIED QNbY rhqsej\~j=as ja,j:h~fi:y()u.are REGULARLY ASSIGNED TOPRACTICE;l:MERGeNCYj:)RIVIUE~~S,SHQPl49$~~~f(EO WHEREVOU ARE THE DEstGNAIED PERSON TO CO\IE.R.AN~ReAIN\M1I~l"ffOlJOO.NOTREGULARLY PRACTICE. BLANK. ARgS.J~WHfCH.... YOU '.OQ. NQ,..Re&lYLARLy)eMQIlgE~lioULD;at;LgFT........ '..'... '.'.' CategoryB 'CategoryC 1. Type 2 Type 3
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NEUROLOGICAL UI~t::.P.~St::.~ MEDICINE PATIONAL AND PULlV'\..J'''"",,nc RENAL UIOt::.t\')I::O
IMMUNOLOGIC ORIGIN TRANSPLANT MEDiCINE Category B Category C The applicant wuloccasionally perform O( 8~sistinthepetfortnan~ ouheptocedure. Consultation wiu be sought in the event of anticipated or actu8id~fficulties. The applicant will perform the procedure; The applicant WOUld be expected to request consultation only occasionally. Type 1 Type 2 Type 3 Formal SpeCialty Ti"ainingProgratn.,',,.,--,'-'."," c_,_,".'_"0 Limited experh;nce.,.. witt)puffqrmaftraining Extensive it)(tler"iet'llle,,"'i/vltlm;j;ui
PROCEDURES (cont'd)
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'L,l(o DATE As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges ancfagree the clinician's qualifications are appropriate. We have.reviewed supporting documentation submitted for "other" privileges requested by the clinician and have determined that documentation is adequate to verify competency. We f~sfoilows:.. [5(Acceptable review with recommendation of appointment to the clinical staff with clinical privileges as requested. o Acceptable with proctoring.as docllmented bytnedepartmeht Chair and/ordjvjsion Head/QI Liaison. DATE ihrj 7 DEP RTMENTCHAIR