VondaReel

AHP Clinical Privileges Update Form

Department of Surgery

I 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: *

*Privilegesnot 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 reportto be filed with the National Practitioner Databank.

As the Supervising Physician/QI Liaison/Department Chair/Medical Directorl 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 AI-lP's qualifications are appropriate. Since the date of the last

····'l)ppointment, we have reviewed applicable information from the following sources of quality and utilization data:

!a' Annual Evaluationo Student EvaluationEr Annual Review by Dept. Chair or SCA

.12( Medical Record Review.0 Continuing Education Conferences.B Physical & Mental Health related to Job Performance.0 Risk Management Events/Quality Management Reports for claimsg Prescriptive Privileges (8 hours continuing education documentation required every 2 years)Other ~ ~ ~ _

We find as follows:

Ijg 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 privilegesas requested, but subieot t a review in _.__ months.

~ Date

~ 1\3 J \c)~i!.yfD~.~~II·Oj f I D

• Date

\( \,v

Robert Sawyer. M.D.Printed Name

J. F. Calland, M.D.Printed Name

Jeffrey Young. M.D.Printed Name

Ca'(o~ A .'Tad'\<e Leo/" .Printed Name

Printed Name

Irving Kron. M.D.Printed Name revised 3/1/2005

· Vonda Reel

AHP Clinical Privileges Update Form

Department of Surgery

I 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: *

Practi

*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 Practitioner Databank.

Date

As the Supervising Physician/QI LiaisonlDepartment ChairlMedical 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 last

/-', appointment, we have reviewed applicable information from the following sources of quality and utilization data:

0' Annual Evaluationo Student Evaluationo Annual Review by Dept. Chair or SCA

rif Medical Record Reviewo Continuing Education Conferencesg' Physical & Mental Health related to Job Performance13' Risk Management Events/Quality Management Reports for claimso Prescriptive Privileges (8 hours continuing education documentation required every 2 years)Other --~-------------------------------------------------------------------------------

Acceptable review with recommendation of reappointment with clinical privileges as requested.

D Concerns noted on review with corrective action plan in place with recommendation of reappointment with privilegesas requested, but subject to a review in __ months.

Date

, .. -----:::------Date

O,ate

Robert Sawyer, M.D.Signature Printed Name

J. F. Calland, M.D.Printed Name

Jeffrey Young. M.D.Printed Name

Alternate Supervising Physician Signature Printed Name

Clinic I are Svcs Administrator (for Me employees) Printed Name

Irving Kron, M,O.Printed Name revised 3/1/2005

Privilege List for: Acute Care Nurse Practitioner28-Apr-09

Name: --'iJlntia. i2e e k Dat,,, ~/t-r---

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PLEASE MARK AS REQUESTED ONLY TIlOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCYPRMLEGES SHOULD BE MARKED WHERE YOU ARE 1liE 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 PRMLEGE

r--"-----A--The applicant will not undertake patient mmagement except in emergen~~ -.------------~~It B The applicant will manage patients with physician present.L _.__C_Th_e_3_

pp_I_ic_an_t_w_il_l_m_an_ag_e_P3_tJ_·en_ts_in_co_1I3_bo_r_a_tio_n_an_dJ_o_rco_n_Su_lta_tiOnwith the physician.

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Neonatal Ped Adol Adult Geriatric

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Adjust Cardiac Assist DevicesAdjust Intra-Aortic Balloon Pump SettingsAdjust Pacemaker SettingsAdjustment of InfusionsAllergen ImmunotherapyAmbulatory Halux 02 SaturationAnesthesia - Nitrous Oxide AnalgesiaAnesthesia LocalAnesthesia RegionalAnoscopyArterial Blood GasArterial Blood Gas PunctureArterial line placementArterial Line RemovalArterial Sheath Removal - >4 in.ArthrocentesisAudiometryAV Fistula Sheath RemovalBone Marrow AspirationBreath Hydrogen TestCamino Bolt RemovalCentral Line Placement & Mgt.Central Venous Line PlacementCentral Venous Line RewireCerumen Impaction RemovalChemotherapy - POIIV/IntrathecalChest Tubes - Clamp and/or RemoveChest Tu bes - Insertion & MgtConscious SedationCPREar Wicks - Insert & RemoveEMGEMG BiofeedbackEndotracheal IntubationEpicardial Pacing Wire RemovalExtubationForeign Body Removal - External auditoryForeign Body Removal - NasalForeign Body Removal- SubcutaneousForeign Body Removal - SubungualForeign Body Removal - Vagina

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FracturelDislocations (Closed) Anterior ShoulderFracturelDislocations (Closed) App Immobiliz DevFracturelDislocations (Closed) Digiul DislocationFracturelDislocations (Closed) PatellarHansel Smear - Nasal SecretionsHistamine ProvocationIncisionlDrainage of AbscessesInitiation of InfusionsInsert Transvenous PacemakerIntermittent Catheterization TxIntracardiac Catheter RemovalIntradermal Skin TestingIntubation & Mechanical VentilationIV Medications & Fluids - AdministrationJackson Pratt Drain 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 PunctureMediastinal Chest Tube RemovalMicroscope Eval - Breast DischargeMicroscope Eval - Post Coital Cervical MucousMicroscope Eva) - UrineMicroscope Eval- Vaginal SecretionsNail Trephination/RemovalNeedle Biopsy of LiverOmaya ReservoirPAP SmearParacentesisPercutaneous Skin TestingPeripheral Central Venous Line PlacementPulmonary Artery Catheter PlacementPulmonary Artery Catheter RemovalPulmonary Function TestsRemove Transvenous PacemakerSigmoidoscopySlit Lamp ExamSpirometrySurgical AssistSurgical Drain RemovalThoracentesisTonometryTPN OrderingTracheostomy Tubes - RemoveTranstracheal AspirationTypanometryUrodynamic Studies - Percutaneous EMGUrodynamic Studies - Rectal Tube InsertionUrodynamic Studies - Simple Office CystometricsUrodynamic Studies - Urodynamic CatheterizationVenous Sheath RemovalVentriculostomy Catheter RemovalWound Mgt - DebridementWound Mgt - Assess for Functional Integrity

Neonatal Ped Adol Adult Geriatric-,---::...:::..=::::..:..::.;:,-,=-,-,---,----~'5 I 1S i (:S

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Wound Mgt - ClosureWound Mgt - DressingWound Mgt - ElectrocoagulationWound Mgt - ImmobilizationWound Mgt - Removal of Sutures/StaplesWound Mgt - Wound preparationAllergyllmmun Dif Dx & TxArterial Blood Gas InterpretationCardiac RehabCardiovascular Dif Dx & TxCholecystitisCirrhosisCNS InfectionsContraceptive CounselingCVA RehabDermatologic Diseases - Dx & TxDermatomyositisDiabetes MellitusDrug Reaction & OverdoseElectrolyte & Water BalanceEndocrinelMetabolic Dif Dx & TxGeneral Med Dif Dx & TxGeriatric Dif Dx & TxGouty ArthritisGynecologic Routine Dif Dx & TxHealth Maintenance & Disease PreventionHeme/One Dif Dx & TxHepatic Diseases Dif Dx & TxHIV,AIDSICP Adjust Treatment ProtocolsImmunizationImpotence - Evaluation & MgtInfectious Disease Dif Dx & TxInfertility Initial Eval & MgtManagement of an emergency/precipitous deliveryNeurodegenerative DisordersNeurological Dif Dx & TxNutritional Status - Eval & MgtOsteoarthritisPain ManagementPancreatitisPituitary ConditionsPsychophysiologic Dif Dx & TxPulmonary Dif Dx & TxRenal Dif Dx & TxRenal failureRheumatic Fever - AcuteRheumatoid ArthritisRheumatologic/Vasc DifDx & TxSerum SicknessSpinal Shock - MgtThrombophlebitisUrologic Disease - DifDx & TxUrticariaVentilator Weaning MgtAdmissions (with MD collaboration)Dx, Assessment & Mgt

Evaluate- ECGEvaluate. Echocardiogram

Neonatal Ped

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General Evaluate - EEGGeneral Evaluate - Holter MonitoringGeneral Evaluate - Labs

~ General Evaluate - RadiographsGeneral Evaluate - Urodynamic StudiesGeneral Evaluate Exercise Stress TestGeneral Evaluate Ultrasound StudiesGeneral History and PhysicalGeneral Hospital RoundsGeneral Order - ECGGeneral Order » EchocardiogramGeneral Order - EEGGeneral Order - Holter MonitoringGeneral Order - LabsGeneral Order - RadiographsGeneral Order - Urodynamic StudiesGeneral Order ConsultsGeneral Order Exercise Stress TestGeneral Order MedicationsGeneral Order Ultrasound StudiesGeneral Patient EducationGeneral Telephone Triage/Consultation

OTHER PRMLEGES

Neonatal Ped Ado! Adult Geriatric

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As tbe Collaborating Physician and Department Cbair/Service Center Administrator, we have reviewed the above-named practitioner's level of experience, past performance and quality indicators (if renewing privileges) asrelated to requested privileges and agree that the above named practitioners qualifications are appropriate.

5~_~'\~_.DATE

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Dept Chair or Clinical Administrator

Name Printed

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