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33 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 be Added (please indicate category level and type of experience): 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 P actitioners SIgnature As the Supervising Physician/QI Liaison/Department Chair/ Director/ Service Center Administrator, we have reviewed the above-named AHP'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 ~,ppoint ent, we have reviewed applicable information from the following sources of quality and utilization data: ~ cal Record Review ontinuing Education Conferences Physical & Mental Health related to Job Performance o Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o 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 req~ested, b~iew in months. to /7-<-1tIc::'-\ ~~ \...:-.J-~ Deborah Henderson. M.D. Date PrIma Superv ing Physician Signature Printed Name ~1:25?LCCl Date Physician Signature Eve Bargmann. Printed Name M.D. Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Clinical Care Svcs Administrator (forjw.;..en1moyees) Printed Name Robert Strieter. M.D. Chair Chair/RPC Director Signature (for HSF employees) Printed Name revised 3/1/2005
34 Privilege List for: Family Nurse Practitioner Feb-09 Name: 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 r-"-' - -.' A The applicant will not undertake patient management except in emergency. IL _ B The applicant will manage patients with physician present C The applicant will manage patients in collaboration and/or consultation with the physician. --~ i i J r=>, -oced u re _ rocedure,~rocedure 'ocedure Adjust Cardiac Assist Devices Adjust Pacemaker Settings Allergen Immunotherapy Ambulatory Halux 02 Saturation Anesthesia Local Anesthesia Anoscopy Arterial Arthrocentesis Audiometry Regional Blood Gas Biopsy - Endometrial Biopsy - Vulvar BiopsyfRemoval - 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 CPR Cryotherapy Diaphragm Sedation Fitting Doppler Monitoring of Fetus Ear Wicks - Insert EMG EMG Biofeedback Endotracheal Intubation & Remove 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
35 ~-ocedure rocedure /Y-rocedure acedure /~'Qcedure ocedure FracturelDislocations (Closed) App Immobiliz Dev FracturelDislocations (Closed) Digital Dislocation FracturelDislocations (Closed) Patellar Hansel Smear Histamine IncisionlDrainage - Nasal Secretions Provocation of Abscesses Intermittent Catheterization Tx Intracardiac Catheter Removal Intradermal IUD Insertion Skin Testing & Removal Lab Test - Blood Cultures Lab Test - Cervical Lab Test - Dipstick Lab Test - Rectal Cultures Urinalysis Cultures - Draw Lab Test - Soft Tissue Site Cultures Lab Test - Throat Cultures Lab Test - Urethral Lab Test - Vaginal Lumbar Puncture Cultures Cultures 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 Slit Lamp Exam Spirometry Surgical Assist Repair Surgical Drain Removal Thoracentesis Tonometry TPN Ordering Tracheostomy Transtracheal Typanometry Ultrasound Tubes - Remove Aspiration - Fetal Ltd - AFI Ultrasound - Fetal Ltd - Dating 1st Trimester Ultrasound - Fetal Ltd - Fetal Cardiac Activity Ultrasound - Fetal Ltd - Fetal Presentation Urodynamic Studies - Percutaneous EMG
36 ---""'''ocedure rocedure ~edical edical lviedical edical.edical 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 Wound Wound Wound Mgt - Closure Mgt - Dressing Mgt - Electrocoagulation Mgt - Immobilization Wound Mgt - Removal of Sutures/Staples Wound Mgt - Wound preparation Adjustment Allergy/Immun Arthritis Attention Problems Birth Defects Eval Cardiac Dif Dx & Tx Deficit Disabilities Rehab Cardiovascular Cerebral Cholecystitis Cirrhosis Palsy CNS Infections Cognitive Rehab Dif Dx & Tx Congenital Heart Disease Contraceptive Counseling Croup, CVA Rehab epiglottitis Cystic fibrosis Dermatologic Diseases - Dx & Tx Dermatomyositis Diabetes Mellitus Dialysis Mgt Drug Reaction & Overdose Electrolyte & Water Balance Endocrine/Metabolic DifDx & Tx Fractures & Dislocations General Med Dif Dx & Tx General Peds Dif Dx & Tx Geriatric Dif Dx & Tx GI Disease Dif Dx & Tx Gouty Arthritis Gynecologic Routine Dif Dx & Tx Head & Spinal Cord Health Maintenance Injury Health Maintenance & Disease Prevention Heme/One Hepatic HIV, AIDS Hyperbilirubinemia Dif Dx & Tx Diseases Dif Dx & Tx 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
37 ~~edical Jiedical ~edical edical General General General General General General General General General General General General General General General General General General General ~---"~neral _,eneral Neurodegenerative Neurological Newborn Newborn Disorders Dif Dx & Tx Dif Dx & Tx 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 Pulmonary Dif Dx & Tx Renal Dif Dx & Tx Rheumatic Fever - Acute Rheumatic Heart Disease Dif Dx & Tx Rheumatoid Arthritis RheumatologiclVasc DifDx & Tx Serum Sickness Sexual Counseling Spinal Shock - Mgt Thrombophlebitis Urologic Disease - DifDx & Tx Urticaria 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 Consults Order Medications Telephone Triage/Consultation -~:;\<\TTlr--r ""~(' :7T'"lI"'-' =to'===r'===o -=~,"""""I"====:::::';;"""'2""~_...-.::oz::::Ei!!i:!==J:~:",!~=~' :-O:.""?_._::::.T" -=:O::::JI::JIr:x:w~c::::r-"" Dept Chair or Clinical Administrator Name Printed
38
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