_~\ 1P.\Jl T]NIVERSITY \L"'\--::_\-'--_..., -q!vtrginia. CUnical Privileges Update Form

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Annabelle Watts
5 years ago
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2 CUnical Privileges Update Form ~ T]NIVERSITY -q!vtrginia Tracey Krupski Department or Urology ~ HF...ALTH SYSTEM 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 bc Added (please indicate category level and type of experience): Current Privileges not to be Renewed: * ~~ I*Prlvlleges not rel~ewed are not ~eported lis being yol~ntllrlly relinquished unless Ihls Is done while you ~re undcl'lilyestiglltlo~; lor, III return for not conducting In investigatioll or proceeding. Jf privileges are to be reported 118 vollllllllrily relinquished you \will be notified IIl1d receive It copy of tile report to be flied with the J'lIatlolllll PracHfiollel' Datllbank. _~\ 1P.\Jl DATE T As the Division Head/QJ Liaison and Department Chair/Medical Oiredor, we have reviewed the abovenamed clinician's level of expel'ience, past perrol'mance and quality indicators (ir renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date or the last appointment, we have reviewed applicable Information from the following sources of quiulty add utilization data: We ~"follows: 1.Jl~. J.Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D 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. D Should have clinical privileges granted but restricted as follows:, DATE DATE \L"'\--::_\-'--_...., /L ~ DEPARTMENT CHAIR SIGNATUItE IUvl,ed 3iIIl006

12 'Clinical Privileges Update Form UrslVERSITY C!/VIRGINIA Tracey Krupski Department of Urology HEALTH SYsTEM 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:* j*priviieges not renewed are no~ reported as being voluntarily relinquished unless thi~ Is done while you are under Investigation; lor, 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. 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 utilization data: We findjts'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. Should have clinical privileges granted but restricted as follows: \\-\~-Q~ --' DATE DATE Revised 3/112006

$REQUEST FOR CLINICAL PRIVILEGES Department of Urology University of Virginia Health Sciences Center Name Medical School and Year of Graduation. VI{'.lh')\Q (ommo/,(,vtcth-h U()l\lu~.$

13 REQUEST FOR CLINICAL PRIVILEGES Department of Urology University of Virginia Health Sciences Center Name Medical School and Year of Graduation. VI{'.lh')\Q (ommo/,(,vtcth-h U()l\lu~.lt l'lju OOd Ad mitting Privileges? fjyes 0 No Virginia Ambulatory Surgery Center Privileges? ~ Yes o No PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BEMARKED 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 L According to category, enter A, B or C in the REQUESTED column. Category A The applicant will not undertake patient management except in emergency. Category B The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties. Category C Type 1 Type 2 The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally. According to type, enter 1, 2, or 3 in the EXPERIENCE column. Completed Formal Training Program Limited Experience - without formal training Type 3 Extensive Experience - without formal training PRIVilEGES REQUESTED AREAS CATEGORY TYPE REQUESTED EXPERIENCE (A, B or C) (1, 2 or 3) DISEASE Diagnosis and treatment _...u...u..._._ ft..._...«...u...,....,.." n...' Interpretation of tests._---_..._..._--_......_..._......_... Transplant evaluation

INTERPRETATION NEUROGENIC DISORDERS URODYNAMICS Category A Category B According to cbtegory, enter A, The applicant will not undertake the procedure except in emergency.

14 INTERPRETATION NEUROGENIC DISORDERS URODYNAMICS Category A Category B According to cbtegory, enter A, The applicant will not undertake the procedure except in emergency. 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. Category C The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. Type 1 Completed Formal Training Program According to type, enter 1, 2, or 3 in the EXPERIENCE column. Type 2 Limited Experience - without formal training Type 3 Extensive Experience - without formal training I PRIVllEGES-REQUEST~------~~~~ I REQUESTED EXPERIENCE I i fa, 8 or C} (1, 2 or 3) BLADDER Biopsy Cyst, excision Cystectomy Cystogram With contrast Cystotithectomy Cystoscopy Cystotomy Dilation L

15 EPIDIDYMIS KIDNEY Insertion Catheter Stent Instmation anticarcinogenic Lithotripsy Reconstruction/cystoplasty Removal of foreign body Tumor, excision UlS Biopsy Epididymectomy Incision and drainage Repair Biopsy Cyst, excision Dilation, renal pelvis Endoscopy Fistula repair Horseshoe kidney. repair Incision and drainage Insertion Catheter Stent Tube Lithotripsy Nephrectomy Nephrogram/Pyelogram With contrast Nephrolithotomy Nephrolysis Nephropexy Nephrorrhaphy Nephrostomy Nephrotomy Pyelolithotomy L. c.. <., {.

16 PENIS "Rlmn";!1 of foreign Tumor, excision U/S Biopsy Circumcision Excision PROSTATE SEMINAL VESICLES SPERMATIC CORD TESTES/SCROTUM Vesiculectomy Vesiculotomy Excision Hydrocele Lesion Varicocele Biopsy Excision Incision and drainage Orchiectomy Orchiopexy Prosthesis, Insertion (., c... I TUNICA VAGINALIS Excision of hydrocele Incision Puncture aspiration of hydrocele L. I

17 CatMter S'ten~ (. c... URETHRA Hypospadias repair Incision and drainage Polyps, ision Tumor, destruction/excision Urethrectomy Urethrograph Urethroplasty Urethroscopy VAS DEFERENS OTHER Repair Vasectomy Vasotomy Conscious sedation L I I

18 As Division Head/Ol Lial$Qn;.. clinician's level of exper'.. related to requested prl. following indicator$ haveb",n mef)j<cht'it~.we have reviewed the above-named tftleitlqea.,o QuaijtY indicators (if renewing privileges) as thatctioiclan's Qualifications are appropriate. The "w~df()r reappointment. Since the date of the least a~p~~~t1we have reviewed applicable information from the following sources ofqualltydatjrt. Physician's Healthar. Men.J$t$JtJs Inpatient AttendJn9PerfQr~ (;~ o Morbidity and Mortality Rem>1!ts J~ftFatnUy Satisfaction ~ll/~y:el'lts/~isk. Management Reports.' J(jn Attending Performance Blood Usage Reports J~n~ puntcaipractice Drug Usage Reports PeElr fivitwof Clinical Performance Infection Reports o Othen. Invasive/Non-Invasive Procedures o Medical Records Documentation We find as follows: ~ceptable review with recommendation of reappointment to the clinical staff with clinical privileges as reque$ted. o Concerns noted on review with corrective action plan in place with.recommen dation of reappointment to the clinical staff with privileges as requested, but subject to a review in _ months. \L-3-~e DATE i L / I I00 DATE DIVirN'HeAO/QI LIAISON Gt)~ "'~HAIR clin_pri.url R:04/11/97

19 Request for Laser Privileges University of Virginia Health System De artment of Ph sician Name: Division of : Please check those types of lasers that you are requesting privileges for, and indicate type of training/experience. TYPE OF EXPERIENCE: 1 Completed Formal Training 2 Limited Experience - without formal training 3 Extensive Experience - without formal training PRIVILEGES Laser Privileges Requested Type of Experience Laser Surgery - Argon 1 "l Laser Surgery - CO2 'j. 'l Laser Surgery - Holmium ':l ":t. Laser Surgery - KTP "l. 1 Laser Surgery - Pulsed C Laser Surgery - Vag Laser Surgery - Lite Sheer v ate I As Division HeadlQI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges and agree that the clinician's qualifications are appropriate. \1--3-u~ Date Date Please return completed form to Clinical Staff Office, Box Rev

Loma Linda University Children s Hospital Loma Linda, CA UROLOGY PRIVILEGE FORM

Loma Linda University Children s Hospital Loma Linda, CA UROLOGY PRIVILEGE FORM Name: Page 1 of 6 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5) All