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18 - AHP Clinical Privileges Update Form Susan Wood, FNP Department of Cardiac Cath Lab have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Prjvile~es to be Added (please indicate category level and type of experience): Nt) ~'C-/;;;? 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 ofthe report to be filed with the National Practitioner Databank. Date, Record Review Annual Evaluation ~Continuing Education Conferences o Student Evaluation ~/Physical & Mental Health related to Job Performance o Annual Review by Dept. Chair or SCA & Risk Management Events/Quality Management Reports for claims o 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.,~r John DiMarco M.D. Printed Name Date Kenneth Belchick. M.D. Printed Name Mike Ragosta. M.D. Printed Name Date Larry Gimple. M.D. Printed Name _'_1_.-:: :.-. -",0_0..;..' ~~ ~~~t::..::~~9~~!:!::~~==== karen Forsman, Administrator Date vcs Administrator (for MC employees) Printed Name Date Chair/RPC Director Signature (for HSF employees) Printed Name revised3/1/2005
19 Privilege List for Family Nurse Practitioner 07-0ct-08 Name: ~'\"6G0 Date: \ 01 15' D"t) 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 Pacemaker Settings Allergen Immunotherapy Ambulatory Halux 02 Saturation Anesthesia Local Anesthesia Regional Anoscopy Arterial Blood Gas Arthrocentesis Audiometry Biopsy - Endometrial Biopsy - Vulvar Biopsy/Removal - Skin Lesion Bone Marrow Aspiration Breath Hydrogen Test Camino Bolt Removal Cardiac Arrest - Assist Cerumen Impaction Removal Chemotherapy - PO/IV/Intrathecal Chest Tubes - Clamp and/or Remove Circumcision Colposcopy - Cervical Biopsy/ECC Condyloma Tx's Conscious Sedation CPR Cryotherapy Diaphragm Fitting Doppler Monitoring of Fetus Ear Wicks - Insert & Remove EMG EMG Biofeedback Endotracheal Intubation Epicardial Pacing Wire Removal Fetal Monitoring Foreign Body Removal - Cornea/Conjunctiva Foreign Body Removal - External auditory Foreign Body Removal - Nasal Foreign Body Removal - Subcutaneous Foreign Body Removal - Subungual Foreign Body Removal- Vagina Fracture/Dislocations (Closed) Anterior Shoulder Neonatal Ped Adol Adult Geriajric f? «: c ~. le ~ C t"'f C-, r; t\. -A A A A C c;
20 c~~, FracturelDislocations (Closed) App Immobiliz Dev FracturelDislocations (Closed) Digital Dislocation FracturelDislocations (Closed) Patellar Hansel Smear - Nasal Secretions Histamine Provocation IncisionlDrainage of Abscesses Intermittent Catheterization Tx Intracardiac Catheter Removal Intradermal Skin Testing IUD Insertion & Removal Lab Test - Blood Cultures - Draw Lab Test - Cervical Cultures Lab Test - Dipstick Urinalysis Lab Test - Rectal Cultures Lab Test - Soft Tissue Site Cultures c Lab Test - Throat Cultures Lab Test - Urethral Cultures Lab Test - Vaginal Cultures Lumbar Puncture Microscope Eval - Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval- Vaginal Secretions Nail Avulsion Nail Trephination/Removal Norplant Insertion & Removal Omaya Reservoir Ortho s - Clavicle Ortho s - Lower Extremities Ortho s - Nasal Ortho s - Ribs - Stable Chest Ortho s - Shoulder Dislocation Ortho s - Upper Extremities PAP Smear Paracentesis Percutaneous Skin Testing Peripheral Central Venous Line Placement Pessary Insertion & Removal Pulmonary Artery Catheter Manipulation Pulmonary Artery Catheter Removal Pulmonary Function Tests Sigmoidoscopy Skin Laceration Repair Slit Lamp Exam Spirometry Surgical Assist Surgical Drain Removal Thoracentesis Tonometry TPN Ordering Tracheostomy Tubes - Remove Transtracheal Aspiration Typanometry Ultrasound - Fetal Ltd - AFI Ultrasound - Fetal Ltd - Dating 1st Trimester Ultrasound - Fetal Ltd - Fetal Cardiac Activity Ultrasound - Fetal Ltd - Fetal Presentation Urodynamic Studies - Percutaneous EMG Neonatal Ped Adol Adult Geriatric A P, 6 13 ~ C. r. ~ /J r L ee '- C C- i5 R ~ d. IS r. c:
21 Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Simple Office Cystometrics Urodynamic Studies - Urodynamic Catheterization Ventricular Catheter Removal Wound Mgt - Debridement Wound Mgt - Assess for Functional Integrity Wound Mgt - Closure Wound Mgt - Dressing Wound Mgt - Electrocoagulatlon Wound Mgt - Immobilization Wound Mgt - Removal of Sutures/Staples Wound Mgt - Wound preparation Adjustment Problems Allergy/Immun Dif Dx & Tx Arthritis Attention Deficit Disabilities Birth Defects Eval Cardiac Rehab Cardiovascular Dif Dx & Tx Cerebral Palsy Cholecystitis Cirrhosis CNS Infections Cognitive Rehab Congenital Heart Disease Contraceptive Counseling Croup, epiglottitis CVA Rehab Cystic fibrosis Dermatologic Diseases - Dx & Tx Dermatomyositis Diabetes Mellitus Dialysis Mgt Drug Reaction & Overdose Electrolyte & Water Balance Endocrine/Metabolic Dif Dx & Tx Fractures & Dislocations Med Dif Dx & Tx Peds Dif Dx & Tx Geriatric Dif Dx & Tx GI Disease Dif Dx & Tx Gouty Arthritis Gynecologic Routine Dif Dx & Tx Head & Spinal Cord Injury Health Maintenance Health Maintenance & Disease Prevention Heme/One Dif Dx & Tx Hepatic Diseases Dif Dx & Tx HIV, AIDS Hyperbilirubinemia ICP Adjust Treatment Protocols Immunization Immunodeficiency Impotence - Evaluation & Mgt Infectious Disease Dif Dx & Tx Infertility Initial Eval & Mgt Malabsorption Management of an emergency/precipitous delivery Nephrotic Disease Dif Dx & Tx Neonatal Ped Adol Adult Geriatric c. C r: c., ~ 6 {3 13 L C L C L c.; c.. C- (! G tf!, 6- C-- L- C. ('; /' r: c.. C C Co, C c, 13 /~ c... <; f5 IS. c. <- C L- r C f;f., 6,A r- r ;3 IS D 6
22 ~~', -~., Neurodegenerative Neurological Disorders Dif Dx & Tx Newborn DifDx & Tx Newborn screening Nutritional Status - Eval & Mgt OB - High Risk Prenatal & Postpart Eval & Mgt OB - Intermed. Risk Prenatal & Postpart Eval & Mgt OB - Routine Prenatal & Postpart Eval & Mgt Osteoarthritis Pain Management Pancreatitis Ped Behavioral Problems Ped Learning & language disabilities Ped Mental retardation Pediatric Emotional Disorders Pituitary Conditions Pre & Post Op Cardiac Care Premature Disorders Dx & Tx Premie Growth & Development Prenatal Counseling Psychophysiologic Dif Dx & Tx Pulmonary Dif Dx & Tx Renal Dif Dx & Tx Rheumatic Fever - Acute Rheumatic Heart Disease Rheumatoid Arthritis RheumatologicJVasc Serum Sickness Sexual Counseling Spinal Shock - Mgt Thrombophlebitis Urologic Urticaria Dif Dx & Tx Disease - Dif Dx & Tx Ventilator Weaning Mgt Admissions Dx, Assessment Evaluate Evaluate Evaluate (with MD collaboration) - ECG & Mgt - Echocardiogram - EEG Evaluate - Holter Monitoring Evaluate Evaluate - Labs - Radiographs Evaluate - Urodynamic Studies History Hospital Order Order Order and Physical Rounds - ECG - Echocardiogram - EEG Order - Holter Monitoring Order Order - Labs - Radiographs Order - Urodynamic Studies Order Order Telephone Consults Medications Triage/Consultation Neonatal Ped Adol Adult Geriatric ; f2, P./ 6 & c. c 6 13 ~ r3 a. C- c. c... C- C-- <:::.- <... C-- C"- c.. c. I 6 ~ C- L I c. L C ~ c. c c, c: C. c. c., (' c. c C - /" if C C c.... C C r: C- C C c. Co C- C <- C C. L <--- c.. C CL <:... c. c, ""-.. c. c,
23 OTHER PRIVILEGES Co.r- d \0\JUS l 0('""'\ Neonatal Ped Adol Adult Geriatric DATE 10/1510"6' 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 '--/.l.l.1d(""""",,~'i-'-"\ -=-D~-=--- _ DATE DATE ~~Q-Q~~..) Primary Supervising Physician Signature Name Printed..Je,bo D,Ji«co ~~ -' kmoslli e,jcb,," Alternate Supervisingp/lCillT\S;gnature Name Printed Name Printed DATE ~!D_~.~oB~ DATE _ Dept Ch ir or Clinical Administrator Name Printed dp 10) 0PjtJ(.----.
AHP Clinical Privileges Update Form Joanne Coleman, FNP Department of Medicine have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to
AHP Clinical Privileges Update Form Mary Stack Department of Anticoagulation Clinic --~,have reviewed the privileges previously granted (copy attached) to me and request the following changes:.ew Privileges
UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Acute Care Nurse Practitioner 29-Sep-10 Name: AnDe Lloy c:i!-il;ul/~y Date: PLEASE MARK AS REQUESTED
FlFALTH SYSTEivI UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: 12-Nov-l0 Family Nurse Practitioner Date:,tloll,o PLEASE MARK AS REQUESTED ONLY
AHP Clinical Privileges Update Form Lisa Laurie Department of Medicine/Cardiology ------- I have reviewed the privileges previously granted (copy attached) to me and request the following changes: New
Effective Dates: 4/23/2014-4/22/2016
Effective Dates: 4/23/2014-4/22/2016 AHP Clinical Privileges Update Form Charles Fisher . Department of MSICU Current Privileges not to be renewed: * *Privileges not renewed
AHP Clinical Privileges Update Form Emily Gilday Department of Neurosurgery I have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to
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
AHP Clinical Privileges Update Form Rose Lewis Department of TCV 4 West I have reviewed the prlvilegespreviouslygranted (copyattached) to me and request the following changes: NewPtivileges to be Added
X X X X X
X X X X X Patricia Schweickert AHP linical Privileges Update Form -:OJ Department of ~. ',- Interventional Neuroradiology I have reviewed the privileges previously granted (copy attached)
AHP linical Privileges Update Form -------. armel Ni\lil Department of Surgery - Breast are I havereviewed theprivilegespreviously granted (eopy.attachedjto me and request the following changes: NewPrivilel!es
AHP Clinical Privileges Update Form Carol Mariscal Department of Radiology ~'"I have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to
VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR SPECIAL PRIVILEGES ADVANCED PRACTICE PROVIDER PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
FOR ADVANCED PROCEDURE S Advanced Procedure Privileges: Are those approved procedural privileges requiring additional education and training and may be granted only upon evidence of initial and ongoing
MONROE CARRELL Jr. CHILDREN S HOSPITAL AT VANDERBILT APPLICATION FOR ADVANCED PROCEDURE PRIVILEGES
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VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR ADVANCED PROCEDURE PRIVILEGES PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
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