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

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Walter Chandler
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19 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 Privileges to be Added (please indicate category level and type of experience): b\~i.n~st:>nt.lc.i>d e. sio.fljs\s' q:nha/j( /)r'd'er8. Current Privileges not to be ren~wed: * "'PriVilegesnot renewed ar~ not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in t~turnfqr.not.~ondllctin,go/ln -i~:yestigationorpr'oceedillg. Ifprivilegesare to be reported as voluntarily rellnquished you will be notifledand rece.ive a.i;opyoftbereportt(lbeni~!l whit tbe Nlitional PrllctitionerDlitabank. Date ~W~-fp~~ Practl ~Signature... f As the $up:elw'isilig'piiytstciani'qlliaison/f)epartlfi,ent'chairtme<1icai Director/ Service Center Administrator, we have reviewed the -above-namedaijp's,levelof experienee, past performance-and quality indicators (if renewing privileges) as related to.requested privjleges and agree that the above mimed AHP'squalifications are appropriate. Since the date of the last.r-r-; appoilltment'wejla~ereviewedappjicableinformationjromthe following sources of quality anduthization data: 'MediCalRecord Review Annual Evaluation tiycolltiiluuigedllc~tiorcortferences:....'..' o Student Evaluation ~P'bysicaij&MentalH~a.lthrelated to JO,b.P~rforIJia.Jlc~ o Annual Review by Dept. Chair or SeA.WRisk~M:ahageinent Events/QulHityManagemeiJt Reports-for claims -'OPr:escriptive Privileges (8 hours continuing education documentation required every2years) Other "~7-~~~ ~~~ --~~~~------~--~ ~~~~ ~ We find as follows: ~cc Ptable.reYh~w'Yfith r~pommendati.onof reappointment with clinicalprivhegesas requested.,rliizl;uo 'but:."st;a~~1j/ Oi S"us d, M.D. D" Concerns aoteden ~eviewwith correctlve action plan in place with Tecommendationof reappointment with privileges Date. Pl'im!iry~upervisingPhysicia'n Signature PririiedName '.'_I ~ I... ' S~!tM0a.vt\,f..tt) ~.. ~L~il!.!llia!!!' ~~I(~ia~8!!:r!::,!!!!a4.D~.!!.:. _..Date Printed Name Date.Alternate Supervising Physician Signature Printed Name Iz Date II ~.r It) I Oa ej r Printed Name Lorna Facteau. DNS. RN. Chief of Nursing Printed Name Date ChairlRPC Director Signature (for HSF employees) Printed Name revised 3/1/2005

20 AHP Clinical Privileges Update Form N1rf~~:o!~~e~ ~n3~~d rypeofexperienc~ lve reviewed the privileges previously granted (copy attached) to me and request the following changes: 5~j~~:f;',~~ == i=?f'~~~l 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. _--,Y}~Il D ) Date Prac tioner's Signature As the Supervising Physician/Ql LiaisonlDepartment Chairf Director/ Service Center Administrator, we have reviewed the above-named AH~P'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 nointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ Record Review. [id' Continuing Education Conferences [;;!' Physical & Mental Health related to Job Performance Q' Risk Management Events/Quality Management Reports for claims Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA ~ Prescriptive Privileges (g hours continuing education documentation required every 2 years) Other We find as follows: 5?'" Acceptable review with reccrnmendatlon of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges s re ested, but SUbjeC1.:: to a revie,,n months. jd~kms ill Date Printed Name Date Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature cl~@i~v~~~'~;m~:!!oyo.') ~.,. Printed Name C. ~ff6rt,m,n"&j Printed Name J Date Chairl!~PC Director Signature (for HSFemployees) Printed Name revised3/1/2005

21 AHP Clinical Privileges Update Form ive reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): /')Y--1!\llprO H O,UD S - ~)Pf V ~ro ':b'f ~ 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. Date As the Supervising Physician/Ql Liaison/Department Chairl Director/ Service Center Administrator, we have reviewed the above-named AH~P'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 :>~ointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ Record Review [;! Continuing Education Conferences [;? Physical & Mental Health related to Job Performance Gtr Risk Management Events/Quality Management Reports for claims Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SeA 5?' Prescriptive Privileges (g hours continuing education documentation required every 2 years) Other _ We find as follows: o Acceptable review with recommendation of reappointment with clinical privileges as requested. Printed Name Date Printed Name Date Alternate Supervising Physician Signature Printed Name 'Date Alternate Supervising Physician Signature H@8O't11: ~. ohm fljv, N ~ Clinic; Care Svcs Administrator (fo:mc employees) Printed Name ~-r G. 'SIfOf...I, M} 11"&1 Printed Name Date Chair/!~PC Director Signature (for HSF employees) Printed Name revised 3/112005

22 ,.;.. Privilege List for: Adult Nurse Practitioner <, J8-Dec-06 Name: Sl,.)z::..o.nYl L() 1\ llt:\.y/)s,. ~S1ljJt~ G-t-J {J 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. '--"'rocedure rocedure "~"rocedure t'rocedure Adjust Cardiac Assist Devices Adjust Pacemaker Settings Allergen Immunotherapy Ambulatory Halux 02 Saturation Anesthesia - Nitrous Oxide Analgesia Anesthesia Local Anesthesia Regional Anoscopy Arterial Blood Gas Arthrocentesis Audiometry BiopsylRemoval - Skin Lesions Bone Marrow Aspiration Breath Hydrogen Test Camino Bolt Removal Cerumen Impaction Removal Chemotherapy - PO/IVlIntrathecal Chest Tubes - Clamp and/or Remove Condyloma Tx's Conscious Sedation CPR Diaphragm Fitting Ear Wicks - Insert & Remove EMG EMG Biofeedback Endotracheal Intubation Epicardial Pacing Wire Removal 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 FracturelDislocations (Closed) App Immobiliz Dev Fracture/Dislocations (Closed) Digital Dislocation FracturelDislocations (Closed) Patellar Hansel Smear - Nasal Secretions Histamine Provocation IncisionlDrainage of Abscesses Neonatal Ped Adol Adult Geriatric C f p., r t Co t t. Co e. c, t. t Co Page 1 of 5

23 <orocedure 2rocedure ~ 'rocedure /~"\>rocedure rocedure Intermittent Catheterization Tx Intracardiac Catheter Removal Intradermal IUD Insertion Skin Testing & Removal Lab Test - Blood Cultures Lab Test - Cervical Cultures Lab Test - Dipstick Urinalysis Lab Test - Rectal Cultures - Draw Lab Test - Soft Tissue Site Cultures Lab Test - Throat Lab Test - Urethral Cultures Cultures Lab Test - Vaginal Cultures Lumbar Puncture Microscope Eval - Breast Discharge Microscope Microscope Eval - Post Coital Cervical Mucous Eval - Urine Microscope Eval- Vaginal Secretions Nail Avulsion Nail Trephination/Removal Norplant Insertion & Removal Omaya Reservoir Ortho s Ortho s Ortho s Ortho s Ortho s - Clavicle - Lower Extremities - Lower Extremities - Nasal - Ribs - Stable Chest Ortho s - Shoulder Dislocation Ortho s PAP Smear Paracentesis - Upper Extremities 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 Slit Lamp Exam Spirometry Repair Surgical Assist Surgical Drain Removal Thoracentesis Tonometry TPN Ordering Tracheostomy Transtracheal Typanometry Tubes - Remove Aspiration Urodynamic Studies - Percutaneous EMG Urodynamic Urodynamic Studies - Rectal Tube Insertion Studies - Simple Office Cystometrics Urodynamic Studies - Urodynamic Catheterization Ventriculostomy Catheter Removal Wound Mgt - Debridement Wound Mgt - Assess for Functional Wound Mgt - Closure Wound Mgt - Dressing Wound Mgt - Electrocoagulation Integrity Neonatal Ped Adol Adult Geriatric r r r e. (. c. e. C. e. (' s a. & c o t t r {' c r. r t.. g Page 2 of 5

24 ""rocedure Aedical ~ ledical /~edical Iedical Wound Mgt - Immobilization Wound Mgt - Removal of Sutures/Staples Wound Mgt - Wound preparation Allergy/lmmun Arthritis Cardiac Rehab Cardiovascular Cholecystitis Cirrhosis CNS Infections Contraceptive Dif Dx & Tx Dif Dx & Tx Counseling CVARehab Dermatologic Diseases - Dx & Tx Dermatomyositis Diabetes Mellitus Drug Reaction & Overdose Electrolyte & Water Balance EndocrinelMetabolic Fractures Geriatric & Dislocations Med Dif Dx & Tx Dit' Dx & Tx GI Disease Dif Dx & Tx Gouty Arthritis Dif Dx & Tx 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 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 Neurodegenerative Neurological Disorders Dif Dx & Tx Nutritional Status - Eval & Mgt Osteoarthritis Pain Management Pancreatitis Pituitary Conditions Pre and Post-Op Cardiac Care. Psychophysiologic Dif Dx & Tx Pulmonary Dif Dx & Tx Renal Dif Dx & Tx Rheumatic Fever - Acute Rheumatic Heart Disease Rheumatic Heart Disease Rheumatic Heart Disease Rheumatoid Arthritis Rheumatologic/Vasc DifDx & Tx Serum Sexual Sickness Counseling Neonatal Ped Adol Adult Geriatric c c, c, e. r e. e f' L C c, L ~ f' c C- f" t: C. (I C. e t. (' t L { r r e r. "(l (. t. c t.. C. ~ I' r Co t: t L e, t L C ~ Co Page 3 of 5

25 >1edical.vledical Spinal Shock - Mgt Thrombophlebitis Urologic Disease - Dif Dx & Tx Urticaria Ventilator Weaning Mgt Admissions (with MD collaboration) Dx, Assessment & Mgt Evaluate - ECG Evaluate - Echocardiogram Evaluate - EEG Evaluate - Holter Monitoring Evaluate - Labs Evaluate - Radiographs Evaluate - Urodynamic Studies History and Physical Hospital Rounds Order- ECG Order - Echocardiogram Order-EEG Order - Holter Monitoring Order - Labs Order - Radiographs Order - Urodynamic Studies Order Consults Order Medications Patient Education Telephone Triage/Consultation Neonatal < Ped Adol Adult Geriatric e.. (I. {I r,. b.. i!i 6 e. c, e. c. e. e. l' t /I c C. r ;:- I' C. Page 4 of 5

26 OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric DATE 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 n~med practitioner ualifications are appropriate. (-vf~/to DATE Name Printed DATE \'/2-zjrx" I Name Printed DATE Alternate Supervising Physician Signature Name Printed ~, DATE DATE f~ 1d.IIO~ Alternate Supervising Physician Signature Name Printed Clinical Administrator 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