Clinical Privileges Update Form Kenneth Liu 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 training necessary to perform new privileges requelrted. (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: '" Privileges not renewed are not reported as being voluntarily relinquished unless this is done or, in return for not conducting an investigation or proceeding, If privileges are to be repo d will be notified and receive a copy ofthe report to be filed with the National Practitioner a b e yare under investigation; uutarlly relinquished you DATE 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 uf 'zation data:. We fi~d s 110 s:.... c ptable review with recommendation of reappointment to the clinical staff with clinical privileges as quested L Concerns noted on review with corrective action plan in place with recommzdation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. (.7/Jju) o Should have clinical privileges granted but r DATE DATE DEPARTMENT CHAIR SIGNATURE Revised 3/111006

UVA. Medical Center, UVA. Transitional Care Hospital & UVA. Health South Rehabilitation Hospital REQUEST FOR CLINICAL PRIVILEGES Department of Radiology itmk1h c.., L\ LA Name I,.,Il"t?f5nt X ~tfd?j ljb<1f7.hba: 1~ \ MediCal School and Year of Graduation ~~~ ~1I1l-~ ~of2- i1jq'-?-rflt.r Board Certification in Year of Certification Admitting Privileges? 6s DNo Transitional Care Hospital? G!Yes DNo 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 NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. Category A Category B CategoryC Type 1 Type 2 Type 3 The The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual ~CUlties. The applicant willindependently~anage patie~ts. The applicant would be expected to request consultation only occasionally. type, enter 1, Program Extensive EXAArience.; withoutf0rn'laltralni!"lg or in the EXPERIENCE column. BREAST IMAGING CHEST RADIOLOGY INTERVENTIONAL RADIOLOGY

NEURORADIOLOGY NUCLEAR MEDICINE PEDIATRIC RADIOLOGY Category A Category B Category C Type 1 The applicant will occasionally perform or assist in the performance of the procedure. Consultation will be sought in the event of anticipated or actual difficulties. The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. Com ACl~rc1m{J to type, enter 1, 2, or inthe column. Type 2 Type 3 Limited Experience - without formal training Extensive Experience without formal training ---------------~~--------------~-~---------------------- PRIVILEGES REQUESTED AREAS CATEGORY TYPE REQUESTED EXPERIENCE (A, B or C) (1.2 or 3) - - ~-----.~ ~~~-- ---~ _. - ~--- -.~- ~~--~~-~ ~- - ~~- - - - - ~-- ~-~--- --< Conscious sedation CT Cyst/abscess drainage Diagnostic contrast ex~minations Fine needle aspiration and biopsy Fluoroscopy Foreign body extraction Luminal stent insertion MRI Percutaneous tube placement Plain film radiography Stricture duatation Genitou Arltegradeurography Conscious sedation CT Cystography Fallopian tube recanalization Hysterosalpingography Intravenous urography MRI

cont'd BREAST Genitourinary Percutaneous interventional GU procedures Plain film radiography Retrograde pyelqgraphy Retrograde urethrography Ultrasound Voiding cystourethrography ultrasound ConsciOUS sedation Fetal ultrasonography Transabdominal Transvaginal CHEST RADIOLOGY RADIOLOGY ULOSKELETAL RADIOLOGY I+ and tissue and osseous interventional procedures of: extremities, spine and its compartments, and all

,. DATE

I ~---------~-- -----~- Page 5 ~ -----------------~------- --- As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that clinician's qualifications are appropriate. 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 Infection Reports Invasive/Non-Invasive Procedures Medical Records Documentation Patient/Family Satisfaction Sentinel Events/Risk Management Reports Consultation Attending Performance Outpatient Clinical Practice Peer Review of Clinical 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 plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in _ months. ~/0. A --.-:. ~ ce.-;~~iv.~.~io~nilh~.~.i~l;ia;is~o~n~--- 6j!:;-i f ~ elin..,pri.rad R:06/21/10