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11 UVA Medical Center, UVA Transitional Care Hospital & UVA Health South Rehabilitation Hospital REQUEST FOR CLINICAL PRIVILEGES Department of Medicine 2,!inn I-/;Z (s..'.' Medical School and Year of Graduation....i'.'. Snr<--' Iq 18- Jq 9 ( Residency Training LocaflOn and Years I Of f J- I q g :1 - S.e... Fellowship Training location and Years :;J.-oterrletJ fy}e d-i'q 1-c.... Board Certification(s) in 19f23 Admitting Privileges? DYes o UVA Transitional Care Hospital? DYes urno -.:I PLEASE MARK AS REQUESTED ONLY THOSE. AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PR1VILEGESSHOULP BE MARKEO WHERE YOU ARE THE DESIGNATED PERSON TO COVERAN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS INWHICHYOypg'NOTREGUtARLYPRACTICE,SHOULD BE LEFT Category B Category C 1 Type 2 The;EiPpliC$nt wiuoionl!ijtiyll'lanage pati.fit$orsistin management. Consultation witl be sought in the event of antlofpatesior' auafdifficulties. The applicantwill independently manage patients. The applicant would be expected to request consu.ltatioh onlysionauy. Formal Specialty Training Program Umited Expetieliloce.,wlthoutformaltraining Extensive Experieil?e':' Wlrrll"llll',1'l'\l'lm1 tji,\i...n column.
12 CATEGORY TYPE PRIVILEGES REQUESTED AREAS REQUESTED EXPERIENCE (A, B or C) ( &/or 4) CARDIOVASCULAR DISEASES Differential diagnosis and treatment Acute myocardial infarction With shock With arrhythmia With cardiac arrest CLINICAL PHARMACOLOGY CRITICALCARE MEDICINE Myoear(Jitis Pericarditis Rheumatic fever Stable angina pectoris Unl!ltal)leangina pectoris Valvular heart diseal!le Differential diagnosis and treatment Drug reaction and overdose Drug-related disorder Oiff$rential dia{jnosis and treatment Ac:lI;lIt ftpiratotyl:)istresssyndrome O(U9.mteractions A A ENDOCRINE AND METABOLIC DISEASES Sepsis Differential diagnosis and treatment Addi-so-n's-Ws -e-a r Aldosteronism Cushing's syndrome Diabetes Mellitus NIDO 100M Wittl.acidolli$ A Male or female infertility
13 I. MEDICAL (cont'd) Page CATEGORY TYPE PRIVILEGES REQUESTED AREAS REQUESTED EXPERIENCE (A, B 01 C) (1,2,3 &Ior 4) ENDOCRINE AND METABOLIC DISEASES Parathyroid conditions (cont'd) Pheochromocytoma Pituitary conditions Thyroid conditions Ofer ".,,"> -,.,:" " EMERGENCY MEDICAL SERVICES Orj'fere'l1.tial di,gtl.ois 'and lrtatment Airway 'man$tllr:!t CardioputrijO"ry fesq$citatlijn Medical emergent'cal'e Toxicology Trauma ' GASTROINTESTINAL AND Differential diagnosis and'treatment C/ HEPATOBILIARY DISEASES Cholecystitis Cirrhosis With bleeding varices GENERAL MEDICINE GERIATRIC AND REHABILITATIVE MEDICINE HEMATOLOGICAL AND ONCOLOGICAL DISEASES Hepatitis Decompensated,; Malabsorption Nutritional disorders Pancreatitis Peptic Ulcer Bleeding k ts t3 Q.." Regional ileitis C- Ulcerative colitis DifferentiaLdiagnosis and treatment Disease prevention Health maintenance f'? Immunization Differential diagnosis and treatment Dementia Stroke rehabilitation " Diffe.:ential diagnosis and treatment Hemorrhagic di,athesis Leukemia Lymphoma Solid Tumor'S leukocyte and red cell disorders
14 w I. MEDICAL (cont'd) Page CATEGORY TYPE PRIVILEGES REQUESTED AREAS REQUESTED EXPERIENCE (A. B 01 C) (1 2.3 &Ior 4) INFECTIOUS DISEASES Differential diagnosis and treatment NEUROLOGICAL DISEASES OCCUPATIONAL AND ENVIRONMENTAL MEDICINE PSYCHOPHYSIOLOGIC DISEASES Bacteremia With shock H1V infection InfectienclQCarc:liti Meningitis Othel'. Different!al diagnosis and treatment ConvulsiVe states A: DegeneratiVe-diseases.. Demyelinating diseases Parkinsonism Stroke Acute RehabiUtation Differential diagnosisanel treatment Asbestosis Environmental diseases Workrelated injuries.. Differenfial diagnosis and treatment Anld.ety Depression r, PULMONARY DISEASEṢ Differential diagnosis and treatment P\ physema monia r.ax.spontaneous ooery infarction onary insufficiency RENAL DISEASES tial diagnosis and treatment k s.ed disorders.d elrqlyteimbalal'le.e NephritiS Nephrotic syndrome Renal failure Urinary tfa.ct infection " B
15 I. MEDICAL (cont'd) Page CATEGORY TYPE PRIVILEGES REQUESTED AREAS REQUESTED EXPERIENCE (A, B Of C) (1,2,3 &/o(4) RHEUMATOLOGIC DISESES. r--, VASCULITIS AND DISEASES OF Differential diagnosis and treatment IMMUNOLOGIC ORIGIN SKIN DISEASES TRANSPLANT MEDICINE A Category B The The applicant will occasionally perform or a.ssist Jnthe performance of the procedure. Consultation wilt be sought in the event of anticipated or actual difficulties. Category C Type 1 Type 2 Type 3 Type The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. A(!l()Tl1in(1 to type, enter 1, 2,3 and/or" in Formal Internal Medicine Training Formal Specialty Training program Limited Experience,... witooljt formatll1ining Extensive Experienoe witht fqfrtlal training column CATEGORY TYPE PRIVILEGES REOUES, ED AHEAS REQUESTED EXPERIENCE (A, B or C) (1 2 3 &/or 4) IMMUNOLOGY
16 PRIVILEGES REQUESTED ALLERGY AND CLINICAL IMMUNOLOGY (cont'd) ASPIRATION PROCEDURES INVASIVE CARDIOVASCULAR PROCEDURES CRITICAL CARE MEDICINE PROCEDURES v,; II. PROCEDURES (cont'd) Page CATEGORY TYPE AREAS REQUESTED EXPERIENCE (A. B or C) (1, 2, 3 & lor 4) ltd n ta erma I S k In testing Percutaneous skin testing Arterial bloodg BonerriafrpwSsplration I Culdocel'lfe.sis. N.asogastric(e.g, sa&tric: nlysi$} 12;, Z- Joint aspiratipn Lumbar puncture Paracentesis f> "J.. Thoracentesis Thyroid Nodule Transtracheal aspiration AICD insertion Balloon pericardiotomy Balloon valvuloplasty Coronaryarthereotomy Coronary stent placement Diagnp$lic cardiac catheterization ElectrophysiolQgic studies IABC Intrapericardialcatheter placement Laser angioplasty Pericardiocente.sis Permanent pacemaker insertiqh. "PICA Radioft'equency-catheter abltion Temporary cardiac pacing. Arterial cannulation Cardiopulmonary resuscitation Chest tube insertion Endotracheal intubation k \ Mec/1anicaJ.veritilatlon Placement of centfallvlines Right heartcatheteraation ThrombolysiS Transtracheal' 02 cannula Venous cutdown " (
17 PROCEDURES ULTRASOUND PROCEDUR OTHER Bone Bone marriow Kidney Liver
18 II. PROCEDURES (cont'd) Page 8 _w CATEGORY TYPE PRIVILEGES REQUESTED AREAS REQUESTED EXPERIENCE other (cont'd) Biopsy (cont'd) (A. B or C) (1, 2, 3 & lor 4) Pleural Skin Thyroid Cannulogram or fjstulagram Cardiac stress testing Cardiopulll)onarystresstesting Cardioversiorr-etectrieal Conscious sedation C- L Electrocardiography Hemodialysis Intercostal nerve block PeritOneal dialysis PICC line plament. mnography Pulmonary function testing Sengstaken or Minnesota tube placement Slit lamp exam Tilt table test Tonometry Trigger point injection Use of conscious sedation 2 Vascular access declotting -=2:::- lr, As Division Head/Ol Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges and agree the clinician's qualifications are appropriate. We have reviewed supporting documentationsubmitted for "other" privileges requested by the clinician and have determined that documentation is adequate to verify competency. We find as follows: lortacceptable review with recommendation of appointment to the clinical staff with clinical privileges as tt<-'requested. o Acceptable with proctoring as documented by the Depa ent Chair d/or Division Head/Ol Liaison.
19 Request for Laser Privileges University of Virginia Health System De artment of Division of : Ph sician Name: Please check those types of lasers that you are requesting privileges for, and indicate type of training/experience. TYPE OF EXPERIENCE: 1 Completed Formal Training 2 Limited Experience - without formal training 3 Extensive Experience - without formal training PRIVILEGES Laser Privileges Reques)ed Tye of Experience Laser Surgery - Argon.V/ C< Laser Surgery - CO2 Laser Surgery - Holmium Laser Surgery - KTP Laser Surgery - Pulsed C Laser Surgery - Yag Laser Surgery - Lite Sheer ignature As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges and agree that the clinician's qualifications are appropria Please return completed form to Clinical Staff Office, Box Rev
Reappointment Privilege Dates: 11/1/ /31/2015
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