-..•AHP Clinical Privileges Update Form

Department of MedicineNonnaBranham, GNP<,

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: *(\:In-e,,

*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.

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Practitioner's Signature

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:

D Medical Record Review~ Continuing Education Conferences

We find as follows:

~ePtable 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

Date

Julia Connelly. M.D.Printed Name

Aval Green. M.D.Printed Name

Printed Name

Printed Name

Lorna Facteau, AdministratorPrinted Name

ChairfRPC Medical Director Signature (for HSF employees) Printed Name revised3/1/2005

AHP Clinical Privileges Update Form

__Norm~&a.nftClh\ Department of !Yl..tdr c{f\.JL.- Q", (~c.:sI have reviewed the privileges previously granted (copy attached) to me and request the following changes:New Privileges to be Added (please indicate cate~ory level and typeof experience): ,

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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.

l1ckYvloQ\ K. &~~ GNPPractitioner's Signature

, I

Date

As the Supervising Physician/Qf Liaison/Department ChairlMedical Director/ Service Center Administrator, we havereviewed the above-named AH:?'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'rppolntment, we have reviewed applicable information from the followingsources of quality and utilization data:

\. Medical Record Reviewg' Continuing Education Conferences~Physical & Mental Health related to Job Performance~'Risk Management Events/Quality Management Reports for claimsQI Prescriptive Privileges (~;hours continuing education documentation required every 2 years)Other _

ff Annual Evaluationo Student Evaluation~ Annual Review by Dept. Chair or SCA

We find as follows://

r;J/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 privilegesas r qu sted, but subject' to a review in // months. .' 1 A /Ir. 1h1\R.

1 \; ___' ~~N~~~.-~-~~--y~~y----ate Printed Name

:fu\tQ G&t\M~~~ __Printed Name 0

Printed Name

Date

Date Altern :de Supervising Physician Signature

/-.~------Date

fOl,O. 107~

Printed Name

---'1Ct~Rer C. -S-Hazr M/I~Printed Name •

Date Chair/RPC Medical Director Signature (for HSFemployees) Printed Name

Privilege List for: Adult Nurse Practitioner31-Aug-06

Name: ~~ It 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 WIllCH YOU DONOT REGULARLY PRACTICE. AREAS IN WIllCH 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.

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Authorized to PrescribeMicroscope Eval - Breast Discharge

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Neonatal Ped Adult GeriatricAdolDermatomyositisPancreatitisLumbar PunctureForeign Body Removal> SubcutaneousOrder - RadiographsOrder- Holter MonitoringOrder· ECGSurgical AssistLab Test- Blood Cultures- DrawLab Test- Soft Tissue Site CulturesOrder MedicationsLab Tesr- Throat CulturesCNS InfectionsHistory and PhysicalTranstracheal AspirationLab Test· Vaginal CulturesHealth Maintenance & Disease PreventionIntradermal Skin TestingChest Tubes > Clamp and/or RemoveImmunizationSigmoidoscopyICP Adjust Treatment ProtocolsUrodynamic Studies- Percutaneous EMGAllergen ImmunotherapyUrodynamic Studies- Rectal Tube InsertionUrodynamic Studies - Simple Office CystometricsIntermittent Catheterization TxTracheostomy Tubes- RemoveOrder » Urodynamic StudiesTelephone Triage/ConsultationHospital RoundsPain ManagementEvaluate- Holter MonitoringCardiac RehabTonometryRheumatologiclVasc Dif Dx & TxEvaluate- EEGRenal Dif Dx & TxAnesthesia LocalEndocrine!Metabolic Dif Dx & Tx.Evaluate- ECGAlIergylImmun Dif Dx & TxCardiovascular Dif Dx & TxOrder » LabsDiabetes MellitusIncision/Drainage of AbscessesDermatologic Diseases> Dx & TxAnoscopyEvaluate· LabsPercutaneous Skin TestingGI Disease Die Dx & TxNephrotic Disease Dif Dx & TxPre and Post-Op Cardiac CareHead & Spinal Cord InjuryMalabsorptionArthritisImmunodeficiencyHealth Maintenance

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Neonatal Ped Adult GeriatricAdolSexual CounselingFractures & DislocationsSkin Laceration RepairNorplant Insertion & RemovalNail AvulsionIUD Insertion & RemovalPessary Insertion & RemovalCondyloma Tx'sConscious SedationDiaphragm FittingBiopsy/Removal - Skin LesionsOrtho Procedures - NasalOrtho Procedures - Ribs - Stable ChestOrtho Procedures - Shoulder DislocationOrtho Procedures - ClavicleOrtho Procedures - Upper ExtremitiesOrtho Procedures - Lower ExtremitiesOrtho Procedures - Lower ExtremitiesRheumatic Heart Disease

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<..OTHER PRIVILEGES

DATE Signature Name Printed

As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the above-named practitioner's level of experience, past performance and uality indicators (if renewing privileges) asrelated to requested privileges and agree that the above named ractitioners qu ificaticns are appropriate.

~11J>-DATE

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DATE

DATE

3-d.-07DATE

Name Printed

Name Printed

Alternate Supervising Physician Signature Name Printed

Alternate Supervising Physician Signature Name Printed

H~R.u.Ar<£-r C. St-loR.'IClinical Administrator Name Printed

Page 4 of 4