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 · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal

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Page 1:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 2:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 3:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 4:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 5:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 6:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 7:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 8:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 9:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 10:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 11:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 12:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 13:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 14:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 15:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 16:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 17:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal
Page 18:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal

AHP Clinical Privileges Update Form

Christine Dubroff, FNP------- Department of Obstetrics and Gynecology

.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):

nj\GlAica.' - "",",0\< ~ o;d-\'-nS C c..) ,\"W"o\,\,\v,o,h\ -ed?ib> (C) , -v-ro \Ot:P-t.- cM'~O\<;s.. (C)'1~tN\ 0('""-4" ever, ~"'1)ca.r<:l\\·Ottf14Y\ I \tt>\h< M.Wlitvv \ \tAk?S, r-c:wh"c9,rHns.,

\A.fO ~4"'~ c, ~elie.5 I CAMCl\..U,h-, V'N~·U+t·CV\> (C.)~~ oJ - t(A-« hQV\.L: ivi Mk-I C:6if\<t'l4 Lh.p· CM. (C)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 Practitioner Databank.

_--"-<\1:11,....:.0_(.\'---- _Date

c~VY~ _Practitioner's SignaturF

As 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 ReviewIi( Continuing Education Conferences 0c;r' Physical & Mental Health related to Job Performance 0Gf'Risk Management Events/Quality Management Reports for claimso Prescriptive Privileges (8 hours continuing education documentation required every 2 years)Other -----------------------------------------------------------------------------------

Annual EvaluationStudent EvaluationAnnual Review by Dept. Chair or SCA

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 privilegesas requested, but subject to a review in __ months.

'I ( lc.t., l D x.. '~~\fV'~

Date ~ervising PYS~ Signature

~ I;).:) Jrf1-Date

Michael Moxley. M.D.Printed Name

Date

Dana Redick. M.D.Printed Name

Jatw SGIMHtt M.O, DeV1.r~ YoI->'"Printed Name /1<,1

Date Alternate Supervising Physician Signature Printed Name

Date Printed Name

~~br.1=D-at";"e~-- James E. Ferguson. M.D.. Chair

Printed Name revised 3/1/2005

Page 19:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal

· ~ AHP Clinical Privileges Update Form

,~Cl1A.l<S hh-L~~Department of_---"Ei__--L-/Lf--=..:.....!-rO _

.rave 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, 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 Practitioner's Signature

As the Supervising PhysicianJIQI Liaison/Department ChairlMedical Director/ Service Center Administrator, we havereviewed the above-named AHlf"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

.e-->, 1pointment, we have reviewed applicabte information from the following sources of quality and utilization data:

~ Medical Record Review~ Continuing Education Conferencesrgf Physical & Mental Health related to Job Performance~ Risk Management Events/Quality Management Reports for claims1&1Prescriptive Privileges (~.hours continuing education documentation required every 2 years)Other -------------------------------------------------------------------------------------

oog

Annual EvaluationStudent EvaluationAnnual Review by Dept. Chair or SCA

We find as follows:

Jii1 Acceptable review with recornmendatlon of reappointment with clinical privileges as requested.

o Concerns noted on review with corrective action plan in place with recommendatias requested, but subject to a review in __ months.

~D l?JL Chvr"r;-h't4I1 Chis hO!JIVlate Primary Supervising Physlclan Signature

o./'J..tz> 10J

Date

~v)?1 g-ed ii LAlternate Supervising Physician Signature...-.-I r" I . ~J 0'" ,., ;> /., Ioto'\... • <l",

Alternate Supervising Physician Signature

Date Altern ate Supervising Physician Signature Printed Name

~Ignature (for HSFemployees) rinted Name

/~a;;~~~

loyees}

C

Page 20:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal

Privilege List for: Family Nurse Practitioner,~ 08-Feb-07

Name: Date:

PLEASE 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 PRNILEGE

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.

ProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedure

Neonatal Ped Adult GeriatricAdolAdjust Cardiac Assist DevicesAdjust Pacemaker SettingsAllergen ImmunotherapyAmbulatory Halux 02 SaturationAnesthesia LocalAnesthesia RegionalAnoscopyArterial Blood GasArthrocentesisAudiometryBiopsy - EndometrialBiopsy - VulvarBiopsyJRemoval - Skin LesionBone Marrow AspirationBreath Hydrogen TestCamino Bolt RemovalCardiac Arrest - AssistCerumen Impaction RemovalChemotherapy - POIIV!IntrathecalChest Tubes - Clamp and/or RemoveCircumcisionColposcopy - Cervical Biopsy/ECCCondyloma Tx'sConscious SedationCPRCryotherapyDiaphragm FittingDoppler Monitoring of FetusEar Wicks - Insert & RemoveEMGEMG BiofeedbackEndotracheal IntubationEpicardial Pacing Wire RemovalFetal MonitoringForeign Body Removal- Cornea/ConjunctivaForeign Body Removal - External auditoryForeign Body Removal - NasalForeign Body Removal - SubcutaneousForeign Body Removal - SubungualForeign Body Removal- Vagina

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C- c, c, c,Page 1 of 5

Page 21:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal

ProcedureProcedure

r+>: ProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedure

/""""'

ProcedureProcedureProcedureProcedureProcedure

Neonatal Ped Adol Adult GeriatricFracturefDislocations (Closed) Anterior ShoulderFracturefDislocations (Closed) App Immobiliz DevFracturefDislocations (Closed) Digital DislocationFracturefDislocations (Closed) PatellarHansel Smear - Nasal SecretionsHistamine ProvocationIncisionfDrainage of AbscessesIntermittent Catheterization TxIntracardiac 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 - Amniotic FluidMicroscope Eval - Breast DischargeMicroscope Eval - Post Coital Cervical MucousMicroscope Eval - UrineMicroscope Eval - Vaginal SecretionsNail AvulsionNail TrephinationlRemovalNorplant 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 AspirationTypanometryUltrasound- Fetal Ltd • AFIUltrasound - Fetal Ltd - Dating 1st TrimesterUltrasound - Fetal Ltd - Fetal Cardiac Activity

C- c.. c, c-

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c: Co c.. r.c c. c, c,c. C- c. c-(.... c.. c, c.c, C- c. c..C- C. o. C.

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Page 2 of 5

Page 22:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal

ProcedureProcedure

~'1'rocedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedical

.~ MedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedical

~,MedicalMedicalMedicalMedicalMedical

Neonatal Ped Adol Adult GeriatricUltrasound - Fetal Ltd - Fetal PresentationUrodynamic Studies - Percutaneous EMGUrodynamic Studies - Rectal Tube InsertionUrodynamic Studies - Simple Office CystometricsUrodynamic Studies - Urodynamic CatheterizationVentricular Catheter RemovalWound Mgt - DebridementWound Mgt - Assess for Functional IntegrityWound Mgt - ClosureWound Mgt - DressingWound Mgt - ElectrocoagulationWound Mgt - ImmobilizationWound Mgt - Removal of Sutures/StaplesWound Mgt - Wound preparationAdjustment ProblemsAlIergylImmun DifDx & TxArthritisAttention Deficit DisabilitiesBirth Defects EvalCardiac RehabCardiovascular DifDx & TxCerebral PalsyCholecystitisCirrhosisCNS InfectionsCognitive RehabCongenital Heart DiseaseContraceptive CounselingCroup, epiglottitisCVARehabCystic fibrosisDermatologic Diseases - Dx & TxDermatomyositisDiabetes MellitusDialysis MgtDrug Reaction & OverdoseElectrolyte & Water BalanceEndocrinelMetabolic Dif Dx & TxFractures & DislocationsGeneral Med Dif Dx & TxGeneral Peds Dif Dx & 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 Dif Dx & TxHIV,AIDSHyperbilirubinemiaICP Adjust Treatment ProtocolsImmunizationImmunodeficiencyImpotence - Evaluation & MgtInfectious Disease Dif Dx & TxInfertility Initial Eval & Mgt

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c... G c c~

C c c C,

c. c c c...r c. c, c-

c. C. c ""Page 3 of 5

Page 23:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal

Medical,~.Medical

VIedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedical

~---...Medical

MedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneral

/ -r-, GeneralGeneralGeneralGeneralGeneralGeneral

MalabsorptionManagement of an emergency/precipitous deliveryNephrotic Disease DifDx & TxNeurodegenerative DisordersNeurological Dif Dx & TxNewborn DifDx & TxNewborn screeningNutritional Status - Eval & MgtOB - High Risk Prenatal & Postpart Eval & MgtOB - Intermed. Risk Prenatal & Postpart Eval & MgtOB - Routine Prenatal & Postpart Eval & MgtOsteoarthritisPain ManagementPancreatitisPed Behavioral ProblemsPed Learning & language disabilitiesPed Mental retardationPediatric Emotional DisordersPituitary ConditionsPre & Post Op Cardiac CarePremature Disorders Dx & TxPremie Growth & DevelopmentPrenatal CounselingPsychophysiologic Dif Dx & TxPulmonary Dif Dx & TxRenal DifDx & TxRheumatic Fever - AcuteRheumatic Heart DiseaseRheumatoid ArthritisRheumatologicNasc DifDx & TxSerum SicknessSexual CounselingSpinal Shock - MgtThrombophlebitisUrologic Disease - DifDx & TxUrticariaVentilator Weaning MgtAdmissions (with MD collaboration)Dx, Assessment & MgtEvaluate - ECGEvaluate - EchocardiogramEvaluate - EEGEvaluate - Holter MonitoringEvaluate - LabsEvaluate - RadiographsEvaluate - Urodynamic StudiesHistory and PhysicalHospital RoundsOrder- ECGOrder - EchocardiogramOrder - EEGOrder - Holter MonitoringOrder - LabsOrder - RadiographsOrder - Urodynamic StudiesOrder ConsultsOrder MedicationsTelephone Triage/Consultation

Neonatal Ped Adol Adult Geriatric

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Page 4 of 5

Page 24:  · Lumbar Puncture Microscope Eval -Amniotic Fluid Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Urine Microscope Eval - Vaginal

, /;1:

Neonatal Ped Adol Adult GeriatricOTHER PRIVILEGES

/- Z:Z--OrSignatureDATE Name Printed

DATE

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) asrelated to requested privileges and agree that the above named practitioners qualifications are appropriate.

q O2s.Lp~h" S."};rlmary upervismg ysrcian igna re

I\--'c---.v/,u~p""~ Ph.Oi.. 'i•••,,,, 1i.t'I<I tl.eti. icJt: IW?

Name Printed

Name Printed

DATE

DATE

DATE

-----DATE

Page 5 of 5