AHPClinical Privileges Update Form

,David Mercer~ ... Department of Wound, Ostomy

Lhavereviewed the privil~ges previously granted (copy attached) to me and request the following changes:NewPrivilcgesto,beAdded'(pleaseindicate category level and type of experience):~A,·,,~o (2~jt-$

Current Priviteges'DQtiobe reiu;~wed,: ~M}lj l.Jc.G.~~. ".

•*,Pl'ivihlgeS!lo~ l'enewedal"e~Qt reported as,helngyoluntarilyrelinquished unless this. is dorie while you areunder investigation; or, inreturn for'not,con~~ctinglln lQveStigation.01' proci!eding. If privileges are to be reported as voluntarily relinquished you will be notified andreeceieve'ai(5PY: oftherepodto be,filed ~itl1the 'Nationa! . 'oner Databank. .

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t\~".t~~.,$~i>er!Y;~in~'p~y~iCian/QI..,Liaison/l)~p'artlfient,C~airlMedical Directorl Service Center Administrator; we havereyie'Ye~tij~llb()v~~mllll~,~,.AHP'slevel··.ofexperlence,.past,performance ,and"qualityindicators (if renewing privileges) asreiafedJ9requested privilege~an~ ;~gree~hat the above named AHP's qualifications are appropriate. Since the date of the last

..~ appoi~tfueilt, webave !ev:iewedap,plicable inform~t-i,onfrom~the following sources Ofquality and utilization data:

...Qj ,.Medic~t'ReC0rdR~view, . .:o •.·qQ~~invi~~E#u~atiq*Cqllf~rences...

.0. ·Phy~ic~I.~;M~Jit~H·1jt)a]t~fe.latedto.Job Performanced R:ifi~Man~gem~nl..Bven'ts/Q~ality'Mal1agemen~ :Reports for claims

.'~ Pre~criptive Pnvi'leges (8hourscontinuing education documentation required every 2 years)Oth¢f' .',

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Annual EvaluationStudent EvaluationAnnual Review by Dept. Chair or SeA

¥A~.~~rev~~h ~~0mnfendoUOO.fre..,poinfmentWi~clinical~ri.".'.es asrequested,

o Concel'll~,not,edon revieww,ith.correcl.ive actlen planin place with recommendation of reappointment with privilegesasreql!oested. butsul?jectto ~ review. in months.

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Charles Friel, M.D.Printed'Name

AmirJazaeri, M.D.Printed Name

Date .:AI,ternat~Supervising Physician Signature Printed Name

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Printed NameM~q)£.Clinical C~re SV,csAdmihistrator (for Me employees)

Lorna Facteau, DNS. RN. Chief of NursirmPrintecfName

Date Chair/RPC Medical Director Signature (for HSF employees) Printed Name revised 3/1/2005

Privilege List for: Acute Care Nurse Practitioner26-0ct-07

Date: 11- \02 -07

PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCYPRIVILEGES SHOULD BE l'vlARKEDWHERE YOU ARE THE DESIGNATED PERSON TO COVER At"iAREA 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

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.

ProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedure

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ProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedure

. Procedure

ProcedureProcedureProcedureProcedureProcedureProcedure

Neonatal Ped Adol Adult GeriatricAdjust Cardiac Assist DevicesAdjust Intra-Aortic Balloon Pump SettingsAdjust Pacemaker SettingsAdj ustment 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 - POIlV/IntrathecalChest Tubes - Clamp and/or RemoveChest Tubes - 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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~-:ProcedurerrocedureProcedureProcedureProcedureProcedure

Neonatal Ped Adol Adult GeriatricFracturelDislocations (Closed) Anterior ShoulderFracturelDislocations (Closed) App Immobiliz DevFracturelDislocations (Closed) Digital 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 Eval - UrineMicroscope Eval - Vaginal SecretionsNail TrephinationlRemovalNeedle 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

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Neonatal Ped Adult GeriatricAdolWound Mgt - ClosureWound Mgt - DressingWound Mgt - ElectrocoagulationWound Mgt - ImmobilizationWound Mgt - Removal of Sutures/StaplesWound Mgt - Wound preparationAllergy/Immun Dif Dx & TxArterial Blood Gas InterpretationCardiac RehabCardiovascular Dif Dx & TxCholecystitisCirrhosisCNS InfectionsContraceptive CounselingCVARehabDermatologic 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 DifDx & TxmV,AIDSICP Adjust Treatment ProtocolsImmunizationImpotence - Evaluation & MgtInfectious Disease Dif Dx & TxInfertility Initial Eval & MgtManagement of an emergency/precipitous deliveryNeurodegenerative DisordersNeurological DifDx & TxNutritional Status - Eval & MgtOsteoarthritisPain ManagementPancreatitisPituitary ConditionsPsychophysiologic DifDx & 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 & MgtEvaluate - ECGEvaluate - Echocardiogram

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Neonatal Ped Adol Adult GeriatricEvaluate - EEGEvaluate - Holter MonitoringEvaluate - LabsEvaluate - RadiographsEvaluate - Urodynamic StudiesEvaluate Exercise Stress TestEvaluate Ultrasound StudiesHistory and PhysicalHospital RoundsOrder - ECGOrder - EchocardiogramOrder - EEG

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General 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 PRIVILEGES

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.

Name PrintedDATE

DATE Alternate Supervising Physician Signature Name Printed

DATE Alternate Supervising Physician Signature Name Printed

Re-~o-c-~ ~~ R.tJ) {VtSUName PrintedDATE