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34 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 THOSE AREAS WHERE YOU ARE REGULARL Y ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGN ATED 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. ~ I C The applicant will manage patients in collaboration and/or consultation with the physician ~f_o~~tk:_met-;.,11a.l~. Adjust Cardiac Assist Devices 1 Adjust Pacemaker Settings Allergen Immunotherapy Ambulatory Halux 02 Saturation Anesthesia Local ~ Anesthesia Regional Anoscopy Arterial Blood Gas ' Arthrocentesis Audiometry Biopsy - Endometrial -----r---~----~--~---- Biopsy - Vulvar Biopsy/Removal - Skin Lesion Bone Marrow Aspiration Breath Hydrogen Test Camino Bolt Removal Cardiac Arrest - Assist Cerumen Impaction Removal -G---f--'(~../--+--"" (r'''''j_ 'l"=j_. _f---'l"",j'---i Chemotherapy - PO/IV/Intrathecal Chest Tubes - Clamp and/or Remove Circumcision f Colposcopy - Cervical Biopsy/ECC Condyloma Tx's -----I ~ 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 c Foreign Body Removal - External auditory U Page 1 of 6
35 UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Family Nurse Practitioner 12-Nov-lO 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 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 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 Cervica Mucous Microscope Eval- Urine Microscope Eval- Vaginal Secretions Nail Avulsion Nail Trephination/Removal Norplant Insertion & Removal Omaya Reservoir Ortho s - Clavicle Ortho s - Lower Extremitie Ortho s - Nasal Ortho s - Ribs - Stable Che~t 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 Date: u IJII,O Neonatal Ped r r ~--~ j Adol Adult Geriatric ----I-----t r:> IS r \-'''i''"--+--'~. 1 ~--~--~--~---~---- ('--./ (1~ ~ ('...I 'l~ r----r---~ ~~~+_-~~ \;,.,~r//j-t--'jl-r:;;.l r i (IJ (I~ ~ _\-."-----1_ ~---r_--- I "--1 \ '-(_~, +---'- ('l...,j l r e Page 2 of 6
36 'j!\ 1 I-IEl\I,TI-I. SYSrEIVl UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Family Nurse Practitioner 12-Nov-l0 Name: JO-OJ(1VLtA L ~D5tvn Date: Pulmonary Function Tests Sigmoidoscopy Skin Laceration Repair Slit Lamp Exam Spirometry Surgical Assist J..d- Surgical Drain Removal V o.cr-~dy1vtta..\,v 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 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 - Electrocoagulation Wound Mgt - Immobilization Wound Mgt - Removal of Sutures/St pies Wound Mgt - Wound preparation Adjustment Problems Allergy/Immun Dif Dx & Tx Arthritis Attention Deficit Disabilities Birth Defects Eval Cardiac Rehab Cardiovascular DifDx & Tx Cerebral Palsy Cholecystitis Cirrhosis CNS Infections Cognitive Rehab Congenital Heart Disease Contraceptive Counseling Croup, epiglottitis CVA Rehab NeonatalPed Adol Adult Geriatric ~ ~-----~ f l ~ - f f i l i ~----~------~ t t------,-~~ ~- f I----~f'.- /-+----Je;'\ ' (l~ f' o: r ' r------i------i i f i l f f j Page 3 of 6
37 UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Family Nurse Practitioner 12-Nov-1O _JQev+1[l~ Name: L.-P05~n Date: ll/j--ii\o Cystic fibrosis Dermatologlc Diseases - Dx & Tx Dermatomyositis Diabetes Mellitus Dialysis Mgt Drug Reaction & Overdose Electrolyte & Water Balance Endocrine/Metabolic Fractures & Dislocations Med DifDx & Tx Geriatric Peds Dif Dx & Tx Dif Dx & Tx GI Disease DifDx Gouty Arthritis & Tx Dif Dx & Tx Gynecologic Routine DifDx & Tx Head & Spinal Cord Injury Health Maintenance Health Maintenance & Disease Prevention Heme/Onc Dif Dx & Tx Hepatic Diseases Dif Dx & Tx mv,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/preci itous delivery Nephrotic Disease DifDx & Tx Neurodegenerative Disorders Neurological DifDx & Tx Newborn DifDx & Tx Newborn screening Nutritional Status - Eval & Mgt OB - High Risk Prenatal & Postpart Eval & Mgt OB - Intermed. Risk Prenatal & Pos part Eval & Mgt OB - Routine Prenatal & Postpart al & Mgt Osteoarthritis Pain Management Pancreatitis Ped Behavioral Problems Ped Learning & language disabilities Ped Mental retardation Pediatric Emotional Disorders Neonatal Ped Adol Adult Geriatric -_ _._ f----- " '1' J (l I (\ (\.; ~ ~ 1; 1./ (L, T.J '\..I (l~ ('./,~ 11-.,.~ (T/ (, n./ 'j 'I) ~ 71,/ [T/ _..- "J (1/ (-. - ( 'J _.._- -- ~ y, --. ~ I--g -~ ' \,/ ('.. 1,/ {lj '/ 'I""f/ j---.._- r nj (t', '""' Page 4 of 6
38 UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Family Nurse Practitioner 12-Nov-JO Name; JDOYH1Q L-.l'OGwn Pituitary Conditions Pre & Post Op Cardiac Care Premature Disorders Dx & Tx Premie Growth & Development Prenatal Counseling Psychophysiologic Dif Dx & Tx Pulmonary DifDx & Tx Renal Dif Dx & Tx Rheumatic Fever - Acute Rheumatic Heart Disease Rheumatoid Arthritis RheumatologicNasc Dif Dx & Tx Serum Sickness Sexual Counseling Spinal Shock - Mgt Thrombophlebitis Urologic Disease - DifDx & 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 Telephone Triage/Consultation Neonatal Ped Adol Adult Geriatric -- ; I _ r~ ~ ') /', (!./ l'.j n b rj '/ 'I..., l0- ~ 1-6 '/',~ f ry/ Itl 7./ ('- ~ [T) -- n./ l'1./ r'".1 l..., t» 1) 1:.,/ ~~ ( '..,; '.) Q" ~/ './ hi...! I..) l:/.'.." (I... rl) - Page 5 of 6
39 UVA Center, UVA Transitional Care Hospital UVA Health South Rehabilitation Hospital Privilege List for: Family Nurse Practitioner 12-Nov-1O Name: JOO.J1 Yll1 L.9oston Date: u I~lll 0 OTHERPRIVIL~E~~. b Ir1 '1/:t.I/ID N~ p~ AC{ A~t Geri~ ~t1llt1(~)(j e DtG'~cJ.l~ _ ml.p(k~ 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{J?;).I,e DATE.. n Name Printed rgal~man....1j1~.~.i.~_ql5:>..... DATE Name Printed DATE '&'a.lu.li "'1"0 w Y e/ Name Printed DATE Name Printed DATE Name Printed Page 6 of 6
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
- 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 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 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 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
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