Effective Dates: 4/23/2014-4/22/2016

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Geoffrey Basil Smith
5 years ago
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1 Effective Dates: 4/23/2014-4/22/2016

29 AHP Clinical Privileges Update Form Charles Fisher <>. Department of MSICU Current Privileges not to be renewed: * *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. If privileges 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. (0- r;)-o-~4 ~ ~ &!j4-civp Date Practitioner's Signature As the Supervising Physician/QI LiaisonlDepartment Chairl Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last ~""""'1}pointment,we have reviewed applicable information from the following sources of quality and utilization data: [if Record Review [9"" Continuing Education Conferences []Y Physical & Mental Health related to Job Performance [g' Risk Management Events/Quality Management Reports for claims ~Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA GY"'Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: ~cceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges as requested, but subject to a review in months. George Verghese, M.D. Printed Name _10 -')o-ct1 Date (0)..]) /2)1 Date,.-J'D)0:J..)b9. Date Alternate Supervising Physician Signature,/1 - "",- C5lJ7W-- ;' / -v"»: ' Clinical Care vcs Administrator (for Me employees) Daryl Gress, M.D. Printed Name Printed Printed Lorna Printed Name Name Facteau Name Chair/RPC Director Signature (for HSF employees) Printed Name revised 3/1/2005

30 Privilege List for Jan-08 Acute Care Nurse Practitioner Name: Date: 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. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE A The applicant will not undertake patient management except in emergency_ B The applicant will manage patients with physician present C The applicant will manage patients in collaboration and/or consultation with the physician "<, Adjust Cardiac Assist Devices Adjust Intra-Aortic Balloon Pump Settings Adjust Pacemaker Settings Adjustment Allergen of Infusions Immunotherapy Ambulatory IiaLlu.02 Saturation ~ f f o 'f l trs Anesthesia - Nitrous Oxide Analgesia Anesthesia Anesthesia Anoscopy Arterial Arterial Arterial Arterial Local Regional Blood Gas Blood Gas Puncture line placement Line Removal Arterial Sheath Removal - >4 in. Arthrocentesis Audiometry AV Fistula Sheath Removal Bone Marrow Aspiration Breath Hydrogen Test Camino Bolt Removal Central Line Placement & Mgt. Central Venous Line Placement Central Venous Line Rewire Cerumen Impaction Removal Chemotherapy - PO/IV/Intrathecal Chest Tubes - Clamp and/or Remove Chest Tubes - Insertion & Mgt Conscious CPR Sedation Ear Wicks - Insert EMG EMG Biofeedback Endotracheal Intubation & Remove Epicardial Pacing Wire Removal Extubation Foreign Bod)' Removal - External auditory Foreign Body Removal - Nasal Foreign Body Removal - Subcutaneous Foreign Body Removal - Subungual Foreign Body Removal - Vagina Neonatal Ped Adol Adult Geriatric -: A- /J-- 'r, r: G C- C..., c. c. r (" C_.. c ~ R r: c C 0 I>' ~ I ~. ~~t.< :?., C., q.-. f-y l2,.i-s./ C A- /-} {] c..- c Ie --'

31 ~'1'rocedure <~ FracturelDislocations (Closed) Anterior Shoulder FracturelDislocations (Closed) App Immobiliz Dev Fracture/Dislocations (Closed) Digital Dislocation Fracture/Dislocations (Closed) Patellar Hansel Smear - Nasal Secretions Histamine Provocation IncisionlDrainage of Abscesses Initiation of Infusions Insert Transvenous Pacemaker Intermittent Catheterization Tx Intracardiac Catheter Removal Intradermal Skin Testing < Intubation & Mechanical Ventilation IV Medications & Fluids - Administration C./ i.jima-t:1 W Jackson Pratt Drain Removal Lab Test - Blood Cultures - Draw Lab Test - Cervical Cultures Lab Test - Dipstick Urinalysis Lab Test - Rectal Cultures Lab Test - Soft Tissue Site Cultures Lab Test - Throat Cultures Lab Test - Urethral Cultures Lab Test - Vaginal Cultures Lumbar Puncture Mediastinal Chest Tube Removal Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval- Urine Microscope Eval- Vaginal Secretions Nail Trephination/Removal Needle Biopsy or Liver Omaya Reservoir PAP Smear Paracentesis Percutaneous Skin Testing Peripheral Central Venous Line Placement Pulmonary Artery Catheter Placement Pulmonary Artery Catheter Removal Pulmonary Function Tests Remove Transvenous Pacemaker Sigmoidoscopy Slit Lamp Exam Spirometry Surgical Assist Surgical Drain Removal Thoracentesis Tonometry TPN Ordering Tracheostomy Tubes - Remove Transtracheal Aspiration Typanometry Urodynamic Studies - Percutaneous EMG Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Simple Office Cystometrics Urodynamic Studies - Urodynamic Catheterization Venous Sheath Removal Ventriculostomy Catheter Removal Wound Mgt - Debridement Wound Mgt - Assess for Functional Integrity -tu-0v.-el~p MIV' ~cv&f1~~~ Neonatal Ped Adol Adult Geriatric R r: fl..s C-- I+- A LJ2r"~»:? r: L_ {~ C C C- C r: t<,,< C ~../ R I:S ~ K R r-. R C_ r. c II I< r: l c. G c. c--' r: r

32 ~ Wound Mgt - Closure '-' 5 t ~ to Wound Mgt - Dressing Wound Mgt - Electrocoagulation Wound Mgt - Immobilization Wound Mgt - Removal of Sutures/Staples Wound Mgt - Wound preparation Allergy/Immun Dif Dx & Tx Arterial Blood Gas Interpretation Cardiac Rehab Cardiovascular Dif Dx & Tx Cholecystitis Cirrhosis CNS Infections Contraceptive Counseling CVA Rehab Dermatologic Diseases - Dx & Tx Dermatomyositis Diabetes Mellitus Drug Reaction & Overdose Electrolyte & Water Balance Endocrine/Metabolic DifDx & Tx Med Dif Dx & Tx Geriatric Dif Dx & Tx Gouty Arthritis Gynecologic Routine Dif Dx & Tx Health Maintenance & Disease Prevention Heme/One Dif Dx & Tx Hepatic Diseases Dif Dx & Tx HIV,AIDS ICP Adjust Treatment Protocols Immunization Impotence - Evaluation & Mgt Infectious Disease Dif Dx & Tx Infertility Initial Eval & Mgt Management of an emergency/precipitous delivery Neurodegenerative Disorders Neurological DifDx & Tx Nutritional Status - Eval & Mgt Osteoarthritis Pain Management Pancreatitis Pituitary Conditions Psychophysiologic Dif Dx & Tx Pulmonary Dif Dx & Tx Renal Dif Dx & Tx Renal failure Rheumatic Fever - Acute Rheumatoid Arthritis RheumatologicNasc DifDx & Tx Serum Sickness Spinal Shock - Mgt Thrombophlebitis Urologic Disease - Dif Dx & Tx Urticaria Ventilator Weaning Mgt Admissions (with MD collaboration) Dx, Assessment & Mgt Evaluate - ECG Evaluate - Echocardiogram Neonatal Ped Adol Adult Geriatric J:lJ,,~ r: G C- c.. r: G C C/ r: G r: C r: G C'_ c... r c..- ~ ~ (2 c r c...- (-:..- c: r: C.- C C r: Ir (' r-:,.,.,- c c: r: f' C-- TJ C- U C...- c. r: c. ( #it";, C- r=. r: r: C-- r: c {"' C- r: ~ {""f C (-:- r: 1"-..-. C «: / G L C-- G. C. C... r: r: e C r: c.., I"' Ir- C C C C C G c: ",-. (7 r./ 0-- c c. C'_ c C C c: C 0

33 Neonatal Ped Adol Adult Geriatric Evaluate - EEG Evaluate - Holter Monitoring ~ Evaluate - Labs r: c. Evaluate - Radiogr aphs {7 C- Evaluate - Urodyn arnic Studies Evaluate Exercise Stress Test Evaluate Ultrasou nd Studies History and Physical {I C- Hospital Rounds r: r= Order - ECG (> c Order - Echocardi ogram C C Order - EEG C ~ Order - Holter Monitoring C- C Order - Labs C C. Order - Radiograp hs C ez, Order - Uredynamiic Studies Order Consults ~ C C Order Exercise Str ess Test C C Order Medications C c:::: Order Ultrasound Studies C c: Patient Education C C Telephone Triage! OTHER PRIVILEGES &-e (l\01~ Consultation Q(1~f C c Clc] Crl-fH~",~qf~," DATE Name Printed As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the abovenamed practitioner's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named practitioners qualifications are appropriate. DATE 2(7(_8'1' DATE ~ _ Name Printed Name Printed DATE Alternate Supervising Physician Signature Name Printed DATF~ffol DATE Name Printe<j- ~Itlt; ;-&/lhilllla Name Printed

AMP Clinical Privileges Update Form Suzann Williams-Rosenthal Department of Internal Medicine Ibaverevie\Vedt~e privileges previously granted (copy.at

$AMP Clinical Privileges Update Form Suzann Williams-Rosenthal Department of Internal Medicine Ibaverevie\Vedt~e privileges previously granted (copy.at$ AMP Clinical Privileges Update Form Suzann Williams-Rosenthal Department of Internal Medicine Ibaverevie\Vedt~e privileges previously granted (copy.attached) to me and request the followingchanges: New