AHP Clinical Privileges Update Form

Denise Bruen Department of Neurology

I have reviewed the privileges previously granted (l~Opyattached) 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, inreturn for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified andreceive a copy of the report to be filed with the National Pra titioner Databank.

lOr 2-1{ l;lo 10Date IAs the Supervising Physician/QI LiaisonlDepartment Chair/Medical Director/ Service Center Administrator, we havereviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) asrelated to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the lastappointment, we have reviewed applicable information from the following sources of quality and utilization data:

'¢.- Medical Record ReviewD Continuing Education ConferencesD Physical & Mental Health related to Job PerformanceD Risk Management Events/Quality Management Reports for claimsD Prescriptive Privileges (8 hours continuing education documentation required every 2 years)Ofuer _

D Annual EvaluationD Student EvaluationD Annual Review by Dept. Chair or SCA

We find as follows:

~cceptable review with recommendation of reappointment with clinical privileges as requested.

D Concerns noted on review with corrective action plan in placewith recommendation of reappointment with privileges

t.

' . as requested, but subject to a eview i!l onths.I J!m',(5!'" "..,. Myla Goldman. M.D.

Date

, Date Printed Name/l/z} 2.010

DateNancy McLinskey. M.D.Printed Name

Printed Name

Date Alternate Supervising Physician Signature Printed Name

Date for Me employees) Printed Name

1/_ }9 - It;

DateKarenJohnston. M.D" Chair

or HSF employees) Printed Name revised3/1/2005

Privilege List for: Adult Nurse Practitioner26-Apr-10

Name:'U.e\i\\ ~-e13v\.A.-e)V1 Date: 5- i3 ,-1 DPLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCYPRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DONOT 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

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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.

GeriatricAdjust Cardiac Assist DevicesAdjust Pacemaker SettingsAllergen ImmunotherapyAmbulatory Halux 02 SaturationAnesthesia - Nitrous Oxide AnalgesiaAnesthesia LocalAnesthesia RegionalAnoscopyArterial Blood GasArthrocentesisAudiometryBiopsy/Removal - Skin LesionsBone Marrow AspirationBreath Hydrogen TestCamino Bolt RemovalCerumen Impac~.RemovalChemotherapy \!!!~- f(lrChest Tubes - Clamp and/or RemoveCondyloma Tx'sConscious SedationCPRDiaphragm FittingEar Wicks - Insert & RemoveEMGEMG BiofeedbackEndotracheal IntubationEpicardial Pacing Wire RemovalForeign Body Removal - Cornea/ConjunctivaForeign Body Removal - External auditoryForeign Body Removal - NasalForeign Body Removal- SubcutaneousForeign Body Removal - SubungualForeign Body Removal - VaginaFracture/Dislocations (Closed) Anterior ShoulderFracturelDislocations (Closed) App Immobiliz DevFracturelDislocations (Closed) Digital DislocationFracturelDislocations (Closed) PatellarHansel Smear - Nasal SecretionsHistamine ProvocationIncision/Drainage of AbscessesIntermittent Catheterization Tx

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Intracardiac Catheter RemovalIntradermal Skin TestingIUD Insertion & RemovalLab Test - Blood Cultures - DrawLab Test - Cervical CulturesLab Test - Dipstick UrinalysisLab Test - Rectal CulturesLab Test - Soft Tissue Site CulturesLab Test - Throat CulturesLab Test - Urethral CulturesLab Test - Vaginal CulturesLumbar PunctureMicroscope Eval - Breast DischargeMicroscope Eval- Post Coital Cervical MucousMicroscope Eval- UrineMicroscope Eval - Vaginal SecretionsNail AvulsionNail Trephination/RemovalNorplant Insertion & RemovalOmaya ReservoirOrtho Procedures - ClavicleOrtho Procedures - Lower ExtremitiesOrtho Procedures - NasalOrtho Procedures - Ribs - Stable ChestOrtho Procedures - Shoulder DislocationOrtho Procedures - Upper ExtremitiesPAP SmearParacentesisPercutaneous Skin TestingPeripheral Central Venous Line PlacementPessary Insertion & RemovalPulmonary Artery Catheter ManipulationPulmonary Artery Catheter RemovalPulmonary Function TestsSigmoidoscopySkin Laceration RepairSlit Lamp ExamSpirometrySurgical AssistSurgical Drain RemovalThoracentesisTonometryTPN OrderingTracheostomy Tubes - RemoveTranstracheal AspirationTypanometryUrodynamic Studies - Percutaneous EMGUrodynamic Studies - Rectal Tube InsertionUrodynamic Studies - Simple Office CystometricsUrodynamic Studies - Urodynamic CatheterizationVentriculostomy Catheter RemovalWound Mgt - DebridementWound Mgt - Assess for Functional IntegrityWound Mgt - ClosureWound Mgt - DressingWound Mgt - ElectrocoagulationWound Mgt - Immobilization

Wound Mgt - Removal of Sutures/StaplesWound Mgt - Wound preparation

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Allergy/lmmun Dif Dx & TxArthritisCardiac RehabCardiovascular DifDx & TxCholecystitisCirrhosisCNS InfectionsContraceptive CounselingCVA RehabDermatologic Diseases - Dx & TxDermatomyositisDiabetes MellitusDrug Reaction & OverdoseElectrolyte & Water BalanceEndocrine/Metabolic Dif Dx & TxFractures & DislocationsGeneral Med DifDx & TxGeriatric Dif Dx & TxGI Disease Dif Dx & TxGouty ArthritisGynecologic Routine Dif Dx & TxHead & Spinal Cord InjuryHealth MaintenanceHealth Maintenance & Disease PreventionHeme/One Dif Dx & TxHepatic Diseases DifDx & TxHIV, AIDSICP Adjust Treatment ProtocolsImmunizationImmunodeficiencyImpotence - Evaluation & MgtInfectious Disease Dif Dx & TxInfertility Initial Eval & MgtMalabsorptionManagement of an emergency/precipitous deliveryNephrotic Disease Dif Dx & TxNeurodegenerative DisordersNeurological Dif Dx & TxNutritional Status - Eval & MgtOsteoarthritisPain ManagementPancreatitisPituitary ConditionsPre and Post-Op Cardiac CarePsychophysiologic Dif Dx & TxPulmonary DifDx & TxRenal DifDx & TxRheumatic Fever - AcuteRheumatic Heart DiseaseRheumatic Heart DiseaseRheumatic Heart DiseaseRheumatoid ArthritisRheumatologicNasc Dif Dx & TxSerum SicknessSexual CounselingSpinal Shock - MgtThrombophlebitis

Urologic Disease - Dif Dx & TxUrticaria

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OTHER PP.~VILEGEStJ\~~ f\AedJ'CL,--h\~ Bd;v\CCL~'ovI

~~~~~. ~~_e~~_l~~_B_V~~~€~~_Name Printed

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As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the above-named practitioner's level of experience, past performance and quality indicators (if renewing privileges) as."Iat~;~:;;~"andagree thatth2a~ualifica~~!4g,~_

DATE ~a~Y@iSing YSI n Signature Name Printed

-D"ATE---~/~J 1°. N""'15 wiLliW>JName Pri e

Alternate Supervising Physician Signature Name PrintedDATE

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Name Printed

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