q' Clinical Privileges Update Form U~lVERSTY '!VRGNA Bhiken Naik Department of Anesthesiology HEALTH SYsTEM 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): tv... Current Privileges not to be Renewed:*,'," '.', ~_'",_W'~","',',''',~,,", "~, '" ",~ : Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; for, in return for not conducting an investigation or proceeding. fprivileges are to be reported as voluntarily relinquished you ;will be notified and receive a copy of the report to be filed with the National Pracf. oner Databank. ~_~thl\ \L~~.~.~._.~. ~.~_ DATE CLNCAN SGNATURE As the Division Head/Q 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 ofthe last appointment, we have reviewed applicable information from the following sources of quality and utilization data:. We fi~s follows: [y'j 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. DATE Should have clinical privileges granted but restricted as follows: "(}.f/t,

Privilege List for Clinical Staff Name: QHf'.EtJ NAr.. 08-Sep-OO DEPARTMENT OF' ANESTHESOLOGY Date:_ 0)'- 2. 'i - 2. D/ 0 PLEASE MARK AS REQUEBTJm ONLY THOSE AJlEA8 WDlBYOU AllEJl'BGtJLARLY AS8JGN.E) TO PBAcnC.; EMERGENCY PlUVU.JtGES SHOULD BBMARCBD WDlBYOU ARB TllBDB8GNA'l'BDl'Q8ON TO cover ANAREA NWRCYOUDONOTUr.GVLARLYPRAC'lC. AJlEA8NWmcHYOUDONO'BBGULARLYPBAcnC.SBOULD BE LEPT BLANK. ACCORDNG TO CATEGORY, BNrERA,B, OR C N TBB BEQUBl'ED COLUMN NEXT TO TBB LBTEJ) Pll1VLEGJt : A Tle ppj/alltwillbot11... petent_~ aceptla_pl)'. B The apjikmtwllloecuiallally...or...~a.e~..the perlormace. CaJaJtdonwllllte _~m."_~~or ~ C '1e.ppUamtwllinde~-.~.pnce4ut. n...0)de4 tereqa.t~ojy...4y. ACCORDNG TO TYPE, ENTER 1,2, OR 31N THE COLUMNS N THE EXl'ElU'ENCECOLUMN: 1 CoJnpWH ronul'l'hdna Pl'oJ'UL 2 JndW Espedau wroaat,...uada. l~e~-,..,."""tnwe ----_...--... < Medleal UVA Outpatient Surgery Center Privileges 13 Yes [] No ADestJaaia/P1in _ =tj ategory 1 Type ExperieDc _. L.'_-=--_ Ra}ueted: Hemodynamic Support Consults C! i Pain Consultation : PainDiffDx&Tx i Pain Managemcnt acute Pain~ chronic Periop U ~ med assess & mgt [ Postoperative~ C. i l Prcoperati":ve Assess C! i Critical Care Critical Care Neurology G i, lcu Unrestricted care C.! Neonatem ~l & mechvent ; PC intubati.on & mech vent PC sedati"on, pain control General Pharmacologic Mgt c Proeedure Airway Control C

Prkilege: Manual assisted ventilation (BVM) Tracheostomy percutana)us ADeltbesiaPala Airway Mgt - LMA insert tintubation, ~cted Airway Mgt -1raCh intub. flex. fiberopti.c. assist Airway Mgt -1racheal intub. ~ pt Airway Mgt 1nCbeal intubation, awake Airway Mgt -lajd8eal.mask airway idsert, restrict Anesthesia -local, epidnral Anesthesia - ~. tie1clblock ADesthesia -loca1.~ Anesthesia-local. JDlij01nerve block Anesthesia -loca.spiual Anesthesia Adminislmt.ion.Anesthesia CQnsciOQS Anesthesia ~ Nerve :Mock: AnesthesiaLoc:al Anesthesia. local-minor nerveblock A1!ethe$ia -g~admin,tore~ ~ Anethesia...~.iJUl!tration.. liurestricted Eehocardio~,.~~ N~. A~.. ~'~pts N~lilr~~,~":~~ PainMgt.. ~ ~. ~..21.~ PainMgt.-.~~~.aibSf~ ljmiam Pain Mgt -~~.:~ form. PainMgt.. ~~ Pain Mgt N~~WQCks PainMgt-~...~ ~ Pain Mgt -PCA.(pt cx)n~11t4~) Pain Mgt -~~.nerveat1l.uon Pain Mgt.. spinal; ~ahotor c;om,fmoos ~on.. CQDSCiOus -i~pts. ~on -~us,d"~pts Sedation.. deep.~pts. Sedation -doep..ojtj~pts. Sedation.. V. ~. Critcal Care MMb81\icai veatila1ioll Emergeaey CPR Catepry ; Type Betprelted i :Experienc G g C C. c G c.. c.. G c. C. C c C. c. C C- Co g C c. j! J 1 J J j 1 1 ), f i J, 2 1 ell c., Co \ C C t C. c.. c.

CateJOl'Y Type Privilege: Requested ExperieDc Bromm~_ ~ ~ C ~ j~ ~ Vutalar Central V CllOlJS<Catheter. nvasive MoDitor - arterial catheters nvasive Mo1itor nvasive Monitor - vascular. UDreSttided DATE OS', i. c centralvenous catheter - tcot - ~Q'O CUNCL\N SC -.TtlRE C (., f ~)J As tile Dmlion HeadQl LiailOD and Department ClaairlMeclieal Diredor. we have reriewed the abovenllred clinician'. level of es:periejke and trabdng 81 related to requestedp and agree tlat the above nllred clinician's quaufleatons are appropriate. Therefore. we tile appintalent to tbe Clinical Staffwit the dlnkal pririleges as requested. 5(11'6, DATE DATE