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Franklin Boone
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52 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 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 unlessthis 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 Practitioner's Signat re 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data:,...--"" ~/ Record Review ~, Continuing Education Conferences 0 [? Physical & Mental Health related to Job Performance 0 ii{ Risk Management Events/Quality Management Reports for claims Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other We find as follows: J Acceptable 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 fas requested, but subject.~o a r~view ~r months. ~{ {:7 IJ 1/ /' /l.,j - _jll 'j1 Q/ Cr-! /)-(: ;I;~(10 ~ Prim' supervu::,ci: 5i.nature B. Gail Macik, M.D. Printed Name Date AI rnate Supervising Physician Signature Matthew Goodman. M.D. Printed Name Date Alternate Supervising Physician Signature Printed Name Date Printed Name 7/30}09.;._~Xi.2i)r1e- j')1c-j.lvlyj~j Date Printed Name Date ical Director Signature (for HSF employees) Printed Name revised 3/1/2005

53 I, 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 witb the National Practitioner Databank. Date to I ~ /O';;f Practitioner's Signature As the Supervising Physiclan/Ql LiaisonlDepartment Chair/ 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data: Y Record Review ~ Annual Evaluation fcontinuing Education Conferences O' Student Evaluation Physical & Mental Health related to Job Performance o Annual Review by Dept. Chair or SCA Risk Management Events/Quality Management Reports for claims ~ Prescriptive Privileges (~;hours continuing education documentation required every 2 years) Other We find as follows:!fo Acceptable review with mcommendation 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 requested, but subject to a revie nn months. li~wt ~'~~~+- ~te ~Q//)- Date Iv} Printed Name Printed Name Date Altern ate Supervising Physician Signature Printed Name Date lvltq{o:f Date Printed Name -re-f--b4 ~ Printed Name Date Chair/RPC Director Signature (for HSFemployees) Printed Name

54 Privilege List for: Family Nurse Practitioner 05-Nov-07 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 LEFf 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 TIle applicant will manage patients with physician present. C The applicant will manage patients in collaboration and/or consultation with the physician, Adjust Cardiac Assist Devices Adjust Pacemaker Settings Allergen Immunotherapy Ambulatory Halux 02 Saturation Anesthesia Anesthesia Anoscopy Arterial Arthrocentesis Audiometry Local Regional Blood Gas Biopsy - Endometrial Biopsy - Vulvar Biopsy/Removal Bone Marrow - Skin Lesion Aspiration Breath Hydrogen Test Camino Bolt Removal Cardiac Arrest - Assist Cerumen Impaction Removal Chemotherapy - PO/IVllntrathecal Chest Tubes - Clamp and/or Remove Circumcision Colposcopy - Cervical Biopsy/ECC Condyloma Conscious CPR Cryotherapy Diaphragm Tx's 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 - Subungnal Foreign Body Removal- Vagina Fracture/Dislocations (Closed) Anterior Shoulder Neonatal Ped Adol Adult Geriatric AIL At AIL Arc.s!«:

55 Fracture/Dislocations (Closed) App Immobiliz Dev Fracture/Dislocations (Closed) Digital Dislocation Fracture/Dislocations (Closed) Patellar Hansel Histamine Smear - Nasal Secretions Incision/Drainage 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 Cultures Urinalysis - Draw Lab Test - Rectal Cultures Lab Test - Soft Tissue Site Cultures Lab Test - Throat Lab Test - Urethral Lab Test - Vaginal Lumbar Puncture Cultures 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 Repair Slit Lamp Exam Spirometry Surgical Assist Surgical Drain Removal Thoracentesis Tonometry TPN Ordering Tracheostomy Transtracheal Typanometry Tubes - Remove Aspiration 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 Neonatal Perl Adol Adult Geriatric

56 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 Problems Allergy/Immun DifDx & Tx Arthritis Attention Deficit Disabilities Birth Defects Eval Cardiac Rehab Cardiovascular DifDx & Tx Cerebral Cholecystitis Cirrhosis Palsy CNS Infections Cognitive Rehab Congenital Heart Disease Contraceptive Croup, CVA Rehab epiglottitis Cystic fibrosis Dermatologic Dermatomyositis Diabetes Dialysis Mgt Mellitus Drug Reaction Counseling Diseases - Dx & Tx & Overdose Electrolyte & Water Balance Endocrine/Metabolic Dif Dx & Tx Fractures General General Geriatric & Dislocations Med Dif Dx & Tx Peds Dif Dx & Tx Dif Dx & Tx GI Disease DifDx Gouty Arthritis & Tx Gynecologic Routine Dif Dx & Tx Head & Spinal Cord Injury Health Maintenance 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 DifDx & Tx Neonatal Pcd Adol Adult Geriatric c. C. C C C c. c. C c. c c. c c c c. c, e c. c,

57 General General General General General General General General General General General General General General General General General General General General General Neurodegenerative Disorders Neurological Dif Dx & Tx Newborn DifDx Newborn Nutritional screening & Tx Status - Eval & Mgt DB - High Risk Prenatal & Postpart Eval & Mgt OB - Intermed, Risk Prenatal & Postpart Eval & Mgt DB - Routine Prenatal & Postpart Eval & Mgt Osteoarthritis Pain Management Pancreatitis Ped Behavioral Problems Ped Learning & language disabilities Ped Mental retardation Pediatric Pituitary Emotional Disorders Conditions Pre & Post Op Cardiac Care Premature Disorders Dx & Tx Premie Growth & Development Prenatal Counseling Psychophysiologic Dif Dx & Tx Pulmonary Dif Dx & Tx Renal DifDx & Tx Rheumatic Fever - Acute Rheumatic Rheumatoid Heart Disease Arthritis RheumatologiclVasc Serum Sickness Sexual Counseling Spinal Shock- Mgt DifDx & Tx Thrombophlebitis Urologic Disease - Dif Dx & Tx Urticaria Ventilator Weaning Mgt Admissions (with MD collaboration) Dx, Assessment & Mgt Evaluate Evaluate Evaluate - ECG - Echocardiogram - EEG Evaluate - Holter Monitoring Evaluate - Labs Evaluate - Radiographs Evaluate Urodynamic Studies History and Physical Hospital Rounds Order» ECG Order «Order«Echocardiogram EEG Order «Holter Monitoring Order - Labs Order» Radiographs Order - Urodynamic Order Consults Order Medications Telephone Studies Triage/Consultation Neonatal Ped Adol Adult Geriatric c. c. c. c, c, c, c. L c, c. c, c... c. c, c c c. c. c c. c c c c c, c, L

58 OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric DATE Signature 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 tbat tbe above named practitioners qualifications are appropriate. DATE DATE } ( 0 L 1- Z 00 ;r ;) JC1 111.l ~\?'4e&~v';7:rt\..J "[3.Gf'iT L (vlac 7:(<- Vi-'j Primary Supervising Physician Signature Name Printed ~~ fl'1~ f"i,, I1)..t.... Good.... AD AIterDlIteS1lPervising Physician Signature Name Printed DATE Alternate Supervising Physician Signature Name Printed DATE Alternate Supervising Physician Signature Name Printed DATE Name Printed

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