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82 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 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 J 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 _~Th~=~:~~:~~::;~:~~:~: 8 The applicant will manage patients With physician present [ p,,:;,. '::O:O:OM~':,":~::h:tPh~~'~ =_~~E~~h'1 c, Adjust Intra-Aortic Balloon Pump Settings f-- Adjust Pacemaker Settings Adjustment of Infusions Allergen Immunotherapy Ambulatory Halux 02 Saturation Anesthesia - Nitrous Oxide Analgesia Anesthesia Local Anesthesia Regional Anoscopy Arterial Blood Gas Arterial Blood Gas Puncture Arterial line placement Arterial 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 Sedation CPR Ear Wicks - lnsert & Remove EMG EMG Biofeedback Endotracheal Intubation Epicardial Pacing Wire Removal Extubation.. c.. ~ ~ _ C==-== ~-~ --- f f----s I-f-:;::-;-'--'~-'~ -CC- - '~l ~ E I-----"==-'i--.J...;..,.,.=T-~-~_1 I 7[; ~ B ~~~r~~'-=f-=icje-l ~ ~ --C.F~±,-- C 0 =-=~= ~ I~~_c_k-_- C-_ ---- t± ~ ~---- ~- -_.. ~---...c_l_ Page 1 of 5
83 UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Acute Care Nurse Practitioner 29-Sep-10 Name: 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 Fracture/Dislocations (Closed) App Immobiliz Dev Fracture/Dislocations (Closed) Digital Dislocation Fracture/Dislocations (Closed) Patellar Hansel Smear - Nasal Secretions Histamine Provocation Incision/Drainage of Abscesses Initiation of Infusions Insert Transvenous Pacemaker Intermittent Catheterization Tx Intracardiac Catheter Removal Intradermal Skin Testing Intubation & Mechanical Ventilation IV Medications & Fluids - Administration 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 of 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 Date: IL/IA/ c r=>: / ') // --- I Neonatal Ped Adol Adult Geriatric -r:= I ~ ~ ~-~ ~ c C C f--_ l ~ --~-.""'p~---l--..:.i-=-'-?--'--- f-- I C -r r: ---Lt---C-- _+---'C=-~_ ( (--+--C~- I t----"(""'--t--~ C~--j- C_ f i-- [-=--+-~ '-R--_r l ,.,-+---n g ire.., h F _ ~==--=-~-----J-----j =tx:': 8 16 I~ Page 2 of 5
84 UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Acute Care Nurse Practitioner 29-Sep-JO Name: - 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 Wound Mgt - Closure Wound Mgt - Dressing Wound Mgt - Electrocoagulation Wound Mgt - Immobilization i Wound Mgt - Removal of sutures/stl~les Wound Mgt - Wound preparation Allergy/lmmun 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 Dif Dx & Tx General Med Dif Dx & Tx Geriatric DifDx & Tx Gouty Arthritis Gynecologic Routine Dif Dx & Tx Health Maintenance & Disease Prevention Heme/One Dif Dx & Tx Hepatic Diseases Dif Dx & Tx Date: 10;/2//0 NconatalPcd Adol Adult Geriatric ~----~-----~ I ~----~ ~ l2 i!>- ~ ± (' C c -.-L~_fL 8 _ C (~i C r r--:i (' I C r C"'-~-'-i--~j "f""""-- (' c. c r--- c c ( C i( L_f---_~[:c I- +_---=---C-~ Page 3 of 5
85 UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Acute Care Nurse Practitioner 29-Sep-10 Name: General General General General General General General General General General General General General General General General General General General 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 - Echocardiogram Evaluate - EEG Evaluate - Holter Monitoring Evaluate - Labs Evaluate - Radiographs Evaluate - Urodynamic Studies Evaluate Exercise Stress Test Evaluate Ultrasound Studies History and Physical Hospital Rounds Order - ECG Order - Echocardiogram Order-EEG Order - Holter Monitoring Order - Labs Order - Radiographs Order - Urodynamic Studies Date: 10/1'2-/10 NeoflatalPed Adol Adult Geriatric ' _.. --1/;1..-W --L&-- c c. C- r r---'c-=--+-'-(_ -I--_C",-,'---I (" c. ( c c c r ~.-- --z; -rr---- c. c C C RC C. c C C _....--~.- r- t-c----_..._--=-- C C. C-- Page 4 of 5
86 UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Acute Care Nurse Practitioner 29-Sep-10 Name: Date: General Order Consults General Order Exercise Stress Test General Order Medications General Ordler Ultrasound Studies General Patient Education General Telephone Triage/Consultation OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric r----- ( ( C- =--=f-- L C C r: C '--- C C r...~ C,~'-.. L L..._ C L C ----c , /.I ICY u/«date (&r1/lliz,,~d tlua~qt3 Anne Uoyd HUJ1! ~ Signature;. Name Printed ' As the CoUaborating 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 _,,0 (~~. _ DATE. (Ol~~tD DATE. [(/3/'''' DATE DATE _ Name Printed ~~'------'--'...Ad('' " S ~ A terna~ Supervising Physician Signature Name Printed SfdfVlG'L~.._----- ~_._tl. ~_r _.;,..., '~ Alterna e Supervising Physician Signature _Ua.r) Name Printed Name Printed --=----T------'=--=----~~"--- ~~tlo../-i--"': --"-,,-()-t+ Name Printed ~,,-t)r Nak~.. -A...;. _ C -('00 I'll U..~f- Page 5 of 5
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
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 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
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
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
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
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
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 Emily Gilday Department of Neurosurgery I have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to
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
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)
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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
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APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) Advanced Procedure Privileges: Are those approved procedural privileges requiring additional education and training and may be granted
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
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