quality and utili

requested

Clinical Privileges Update Form llDSlVERSITY t?1_VIRGINIA

Susan Miller Department of Physical Medicine HEALTH SYsTEM

I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency):

New Privileges to be Added (please indicate category level and type of experience):

Current Privileges not to be Renewed: *

;*Privileg~s not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigatio~; lor, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you iwill be notified and receive a copy of the report to be filed with the National Practitioner Databank.

(DATE ~7 CLINICIAN SIGNATURE

As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the above­named clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Sinc¥he date of the last appointment, we have reviewed applicable information from the following sources of

. n data:

Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as

D Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in __ months.

D

-)+-f-I=~.--~DATE

. ~.~~\~~~--.

Should have clinical privileges granted but restricted as foil

DIVISION H

~ DATE DEPARTMENT CHAIR SIGNATURE

Revised 3/112006

Clinkal Privileges Update FormMiller Department of Physical Medicine

I have reviewed thepr.ivileges previously granted to me and request the following changes to includeany new-therapies, procedures,or additional training n cessaryto perform new privilegesrequested. (please include supporting documentation t verify competency):

New Privile~es to be Addedtplease indicate categoryle vel and type of experie~f c~¥· e..¥.:f

.. ut'Y\bar '~.' - 'otn·f- ~' (Old /' :·e.Bf(0Y\,5" C -:P /tu

Current Privileges not to be Renewed: *

,/"_, ,*PriviIeg¢$.lotr~nell'ed.;re .lot reported;~ being voluntarilyrdinqui~hed unless this is done while you 'are under investigation;;or, in return:f!ir not conductiJlganjnve~tigati.on or prnceeding, If privileges are to be reported as voluntarily relinquished you:will be notified and receive s·cOpyoftberepQrt to be filed witli the National Practitioner Databank,_ ._. _' ~ _, _ _. _ 0.:..; _ _

DATE

AstbeDiviSiQnHead{Q~paIson.andD~pllrtmentCbllir!M.edical Director, Wehave .reviewed..theabove-nllmed cI~nicia~'s lev~l 0'£ experience, past performance and quality indicators (if renewing privileges) asrelated to requested.privilegesan.d agree tbattheabove named cIinicfan'squalifications are appropriate.Since the date~nhe ast appointment, we have reviewed applicable information from tbe following sources ofquality and u .• ion data:

Wefihd asAcc~ptitble review wjthrecommendati(>n of reappointment to the clinical staff with clinical privileges as.reque$ted

D. .

C.Q~c;:~.rnsnot~d~rl review with corrective action plan. in place with recommendation of reappointmenttptheelinicalstaffwith privile'gesas requt;lsted. butsubjectto a review in __ months;

l(!havEi clinical privileges granted. but restric

DATE

f)/ )t1, b •.

f}IVISI~Ni1:"luf P. wit"" /1.0.DEPARTMENT CHAIR SIGNATURE

o

Revised 3/112006

Department 0 Orthopedic SurgerMiller

UJ)JIVERSrry~~IRGINIA!!!!ll! I-Ir:.ALTH SYS1T~1

Clinical Privileges Update Form

I have reviewed the privileges previously granted to me nd request the following changes to includeany new therapies, procedures, or additional training n cessary to perform new privilegesrequested. (please include supporting documentation t verify competency):

New Privileges to be Added (please indicate category Ie el 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, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished youwill be notified and receive a copy of the report to be tiled with the National Practitioner Databank.

DATE CLINICIAN-SIGNATURE

As the Division Head/QI Liaison and Department ChairlMedical Director, we have reviewed the above-named clinician's level of experience-past performance and quality indicators (if renewing privileges) asrelated to requested privileges and agree that the above named clinician's qualifications are appropriate.Since the date of the last appointment, we have reviewed applicable information from the following sources ofquality and utilization data:

We f~~ollows:L0 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as

requested

D Concerns noted on review with corrective action plan in place with recommendation of reappointmentto the clinical staff with privileges as requested, but subject to a review in __ months.

DATE

Should have clinical privileges granted but restricted as follows: _

~ /A/«" AI{?oj }-I,D,Df. lQ~EAD/QI LIAISON SIGNATURE _

\ (}1--:vv1 I D -we-y' K~xnOf-nl )vLl)DEPARTM;tT CHAIR SIGNATUREiJATE

Revised 3/1/2006

Susan Miller f Physical Medicine

U~1JVERSITY'.t!t..ql\jtRGINIA!!!lli! HEALTH SYSTF~M

Clinical Privileges Update Form

I have reviewed the privileges previously granted to m and request the following changes to includeany new therapies, procedures, or additional training necessary to perform new privilegesrequested. (please include supporting documentation t verify competency):

New Privileges to be Added (please indicate category I vel and type of experience):. Co.;f(.J~or...,

(J vi caA id,un So o· d i . cfion S G~ho(acicf~lu~m~~~rl_l ~_' " ~C~J _

Iuro6~ f'ClP-J,.f¥i brCl/ach blocks 0OCCip-('f-CV( () pie, blocks C

e~perienc.£

3/(3/13/13/1

"3/1Edit ent-PriviJeges not to bo Renewed. *"""1

, . ,.

*Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation;or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished youwill be notified and receive a copy of the report to be filed with the National Practitioner Databank.

-DATE #--'--' --- CLINICIAN SIGNATURE

As the Division Head/QI Liaison and Department ChairlMedical Director, we have reviewed the above-named clinician's level of experience, past performance and quality indicators (if renewing privileges) asrelated to requested privileges and agree that the above named clinician's qualifications are appropriate.Since the date of the last appointment, we have reviewed applicable information from the following sources ofquality and utilization data:

We f~s follows: .~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as..' requested

D Concerns noted on review with corrective action plan in place with recommendation of reappointmentto the clinical staff with privileges as requested, but subject to a review in __ months.

o Should have clinical privileges granted but.restricted as follows:. _

Zf:t(o::!-:. C,d3 IAld~alfano, pi, D.DATE ( DlVISIO]'q,~EAD/QI LIAISON SIGNATURE

,- \I;l)) \, ~ //)Ca<eV f!.erri3J() { }1bLlATE J DEPARTM~SIGNATURE

Revised :l/1n006

.'r

REQUEST FOR Cl NICAl PRIVilEGESDepartment of Physical edicine and Rehabilitation

University of Virginia ealth SciencesCenter

SU8~Y1 AI M~\\\~(Name I_(AVa ~ 2(QLMedical SchoolandYearof Graduation IWit, PMtR 2CC>2- P~+...:..-- _ResidencyTrainingLocationand Years--r

Fellowship/Post-ResidencyTrainingLocation and Years

l)'Ulible-" ~1Y\'fQ! C)(O-rn g/tfo.Bo.;(FCert;f;cat;on in I

Admitting Privileges?I

~Yes o No

Year of Certification

PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLYASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHEREYOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOTREGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICESHOULD BE LEFT BLANK.

According to category, enter A, B or C in the REQUESTED column.

According to type, enter 1, 2, or 3 in the EXPER/ENCE column.

Category A The applicant will not undertake patient management except in emergency.,

Category B The applicant will occasionally manage patients or assist in management. Consultation will besought in the event of anticipated or actual difficulties.

Category C The applicant will independently manage patients. The applicant would be expected to requestconsultation only occasionally.

Type 1

Type 2

Type 3

Completed Formal Training Program

Limited Experience - without formal training

Extensive Experience - without formal training

Diagnosis and Treatment 1-A~'~te-My-;~~~di~i-i~f~~~t'i';~"'--"----'--"-'--'- -_ "%..-..(5:. '-':'--''''''i''''-'-'-'-'-BrC;~-~'hitid;s--"--"'-"'''''-'--''''''''''''--''''-''-''---''- _ :f('---'A-' ._ ::;_._ ... _._.._ _.__ _ _ __ _.._ _ _ _ '...... _ _k. .

._~~~~~~::!2~~~i.::__._.._._"_..".."_ " ~I.:l.. Pt "_."_..£..." _".Cholecystitis A 7

,- --.....,.

-.,

MEDICAL DISEASES - cont'd Congestive Heart Failure B 2__ • • __ •• _ ••.••._ ••••.• .l.... •.• •._ •..• • •••. __ ..•••••• • •.._ ••...• • _. •• _._. __ ._ ....

Cushing's Syndrome B 2Decumt-~-~nd ==- Dis;rd;:;-"-?-'--'---" -.-- --- --- ..-.-- -- ..

-D·t;b~t~-~·M~iii·t~·~···-·-··--·-·------····---········· -- ..-c:::.- ..-.- -..-.~- - -~----.--- -.-- ----..---- ---.---0::.-._ -···_··3..---·-·-···..--·Disease Prevention 1-'

=~·~·g·-6-~_~~~·-·==~:~-~=:=~:::~=_~~:=~~~==::~-~:~=::==&::=:=~:::.==::::~~:::~~==::Drug Reaction and Overdose 8. 2.-E~p·hy~~·~;·····-····-······-·····---·-·-·-·--··-····-..-..- - -j -- ~..--.

-Fluid ~-;;-d·-ET~·ctroIYt;-lm·ba~-;ce-----·-··· --- i'---" --.-""):.--.-..--.:~~C~~:~~_~~?~~_~~=:=:~~_-======::::~_~:~=~:~~:~~~::A.:~~~:::~:::::::~::~::~~:::~:~~::Health Maintenance 'IS.3

-·H·~~~~~:=~::=:~~~=:J~~_~~~==~=~~~~=::~=~=~~~=~~-=:£~~:=:~::~:~~=:=:~::~~=:~::=Hypertension c.. 1

·-···-·--·············--·······-··-·1····-··-···-···-·.- -.- -- -.-.- -.- ..---.-- -.......... . - - .Infectious Diseases 'IS 3

··-M;~h~ic;i-~~-tilati"c;·;-.;;;d-G·~;;;·;;:;i;g--·--··· '---':f2"-" ··---··-·2-·-····-·--...•..._ ....•.........._ ....•..._._- ..•-. _..__ ._-_ .._ ..__ ..__ .__ _ •........•-•....__ .. •. --_ _._ _ •.............. _ .._ .._..Nephrotic Syndrome .~ ~.._-_ _ _ _ _.._- _ _ __ __ ._ -_._-_ _ __ .J.:::J__ _ -- 4- _-Nutritional Disorders 5 3p-;-Pti;-uk;;~·---·-·---·-··-----·-·--·--· ._-...-. a_.-..-._-...-2.....--..-..

-P;riph~;~i·-vas;:;~-r- Dise~·se--------- E-'-- ----2---·-·:!.~~~~~~:~:::::~:~=::~~:=~~:~~==~:~~~~~=~~~=:=::=~:::~:::~:::~~~:S:~::=::~·:::::=:~::::~::::~~:~~

Pulmonary Infarction p.. 2---_ _..__ .._ .•..•....- _ .._-----_._-_ _.----_ _ - _--- -_ _ _ __ .Pulmonary Insufficiency £. 2

···sy~-~~iti~··-·········-·-··--····-··-···-·········-.._ -- - _ _-.- "C:. - -..-- ]-- -

:!.~:.~~~~?~.~:~!.~~~=::=~====:~==:=~==:::::~=:~::=:=:~:~:~::~::=~::::~::~=:~3..:~==::::::Ulcerative Colitis B 2-

......._ _----_ -•....- _ _ ..•...-._._..- _ .....•••...............•......•_ __ _.- __ _ .._--_.Urinary Tract Infection G 3

RHEUMATOLOGIC DISEASE Diagnosis and Treatment 8. 3.-C"a~di;~iti·s-··-···--··-·--·-·-···--------··"'-"'-6,-..--.....- .-_.-i·_····--·-··-_ ..........•. _ ................•..................... _ -•.....-•....•_ _ -........... •.......•........• . _.................... ...........................•....•••...•••......

Dermatomyositis . & 2-Lt7p~"S--·····-·-·-·-·-··-----··---·----·-··--···· .-...-- ....Q;.-.-.-.--- ---~.-.- ..--.-.···Ost~-~;n·h·~·i·ti;.-·························-····· -.- ············C - \.-- -.- .···Rii~umatoi(TArth~·itis-·-··-··-·····--·--·······---.--.-·-··-····-·5··-·····-····· - - 3: ..----.- ...................•............................................................................................... _.................... ..................................•..•. ..._ .Thematosis (" L

NEURO/PSYCH DISEASES ORINJURY

Diagnosis and Treatment E>.' ~·.·~._.._..·._ .._ _ ..~.._ _._.u .._ _._ _ _ _... ~ ~............. '!' ••• _ .••.•.•••• _ ••.••••.•••• u_..._~.~.~.i.::.:__._ _._.__. _.._. _ __ _ :5.._.._.. _._~. .._.._ .Convulsive States B '2.

···i5·;g~~;~~ti·~·~··Di~·~;~·~·~·-·····-···············- ···············6················ - ::;[ - ..-.-...•.••.---.- ..-.•--.---- -•.•...--..- - ~.--~_ __ __ - - -..~•.........--.•-.. -- ~ -......•-..- -..Depression 2

"

NEURO/PSYCH DISEASES OR

INJURY - cont'dl

Head Injury

Acute Rehabilitation__ .h.._ .._...__ .._._1._. __ .__..

.0 t--_._ .._-_.__ .•.....__ __ -.__ ._------_.__ .-..-_ _ _ •._-_. _._- -.._ .._-yelinating Diseases . .B ~._...•••...--_ ..__ ..__ _.__.__._------_ ..__ .__ _ .._...... -_._-- .._-- ...•---- .

Pain Management .__ G.___ ___ 1._.._. __Acute r l._._._l....:'_._ .._ .._ .. ._..._ .._.__ ..Chronic

...:.:..~.~!.~.~~~!.~~_ _._.._ _ _ _ B. _ _..3 ..-._ .~~ 8 1Acute Rehabilitation -'C-'-"-"-"-' '---',---'--"

-·S-p;~t·i·~·i·tY ····..········.- - ..-.--_ _._ -.- - --·-···..C·················· - ----.-- -.

GENERAL ORTHOPAEDIC

DISORDERS

~.

Diagnosis and Tre tment c.,···A~p~tati-o~s·-·······-· - - -.- .._ - :::==~=~~~===~:=:~·-C=~=

Upper Ext emity .._ _.c.:: _ _ _.1. _._ .Lower Ext emity ~ \_______ ._ ..__.__ _.__ .__ ..__ _. . _n....•. ....•....__ .__.............•.... .•

-·~~~:~~~:~-~:~~···::t-~·~~~=········-······-·······-·-- ·················f····_····· -- -!._.-_.-- ._ ..__ .__ __.._..•....._..__ ._ __.._ _. _~.. 1._.__

Overuse Injuries/Repetitive Trauma C t_ -.- ..---.- _-- - -.--.-.--.---- -.---.- _._ 7"._ -..-_.. ---. __._..-..-..-..-..

Post-operative Care V I---_._ ..__._------_ ..._-_ .._--------, -_ ....-------_ ..- .--.- ..~--...Pre- and Post-operative Care for Joint

...~::!?~~.~.:.~:.~~_ _ _.._ _ _ __ _ _G _ __..1:._ _..Prosthetics C, J_.-.__ .._._--_ .....__ ...._ ...__ ._.._.-._-_._-_ ....._---- .........•..••.•......•... _ .....•-..-...---_ .....----_._.. ---..--_.-Soft Tissue Injuries c... \

-·Sp~r1~;~i·~ted-i;;j"~·ri·~s··-·-···············-·····-·--- - --. ·····-······--c············· ··········-·········1·_··········WOrk~;~T~ted-·i~~-rT~·--·--··-----·---·-····· -_·-·-c-·--- '-"-'-'-- -'---"

SPINE DISORDERS Diagnosis and Treatment C 1_ _-_._ _ ••.........••..•..-.....••.....•.•...••...•- -_ ..•.•- •....•.._ ..-.•.........._ •.....•.....__ ..•..•- ---_ - ......•.•....•..••...

Low Back Pain Syndrome _ :C.._ __ _ .._ L .With Radiculopathy . . ..9.:..._._.._. - -_.--.1....--- ..Without Radiculopathy c., ~

···N·ec-k··Pa·i·;;··S·y~d·;;·~-e··-·-·······-··-··--···--_ - :~~:::=~:~=~:~:~:~:::~~~=~:~~..=:~:=:~:With Radiculopathy C \---_ --.•......._ _ __ ....•-_ _-Without Radiculopathy C. I

-N·~·~~;ge~ic-B;-;~i-;~d·~-BGl~·f--··· .- _ -c::::._. ·······-···_······C·_········

:~~~:~~~!:~~2~~==:=~~~=:~:==:::::~:~=~~~=::~=:~~:=:::~~:::==::~~~::~==:::::::::~~~:::I=:=:::~::Quadraplegia G' I

=~~~~?:~~~..~:==::::~~::~~::=:::::~~:::=:::::::=~::::~~~~~::::~::::~:~::::==:=:::~::~:::~:~~:::::~:~~=~::l:~~~~~:~~:.~in.:! ..:~:.~ ..~~.~~~~:.~~.:.~~.:.._ ._._ _ _ _.__ . _C.__ _ _.._._.~ _..Spine Tumors _ B. ~ _ .

Without Neuro injury B z..-'s~;;;i~itv-"'"-"--"""'-'---"'---"'-"""--"---"" -._ c:::: _.-. _ _.-_ - _.-

".According to category, enter A, B or C in the REQUESTED column.

Category A

Category B

Category C

The applicant will not undertake the pro edure except in emergency.

The applicant will occasionally perform or assist in the performance of the procedure.Consultation will be sought in the event of anticipated or actual difficulties.

The applicant will perform the procedure. The applicant would be expected to requestc:onsultation only occasionally.

According to type, enter 1, 2, or 3 in the EXPERIENCE column.

NEUROMUSCULOSKELETAL

JOINT THERAPEUTICS

Type 1

Type 2Type 3

:',PRIVJLEGES R....:.. . . .. .. ..,.: :'. :' :~. :::, " ", '. ": ..

GENERAL

Completed Formal Training Program

Limited Experience - without formal training

Extensive Experience - without formal training

• .. . ••• •

Acupuncture

~~~~~~~'I-B~~~~~~~~==~"~:=:~~==:::~=~=====:=:~~.~=~ti~~::=~~:·:=~~i~=:~:~=:...~'?'.~9..~..~~!..::.~!.~~.~ _ .___. ._._ 9.: _ .. ._.J_ _Cardiopulmonary Resusc itation

Basic .-- ..[ - --.-2: -..___ ~~~~~:~.._._.._. ..__._.._..__._ ~~::~:=::A:~:~:~~~~~::~=::=:~~~:~~:::~~~Caudal Blocks

~:~~~tr~~~~~·g;~~~~~==~~=:==~~:=~_==:=~=:·=~:=::~::~:~~~~:.::==:~2::~~~~_~...:~!.?.~~~!.~.._._ _ 8. b ...~ist~_~.~:.!~~~~.:~~~~.~_ _ _ __.._ _._._ -- ..:1.\ _ _ ~ _ .Incision and Drainage of Abscess . C. 3·..i~t~ad~~;;;·ai..s·ki·~..T~~ti~g···-··..·· ·..··· ··..·· () 2: .

_ __ _ _ _ _ _.._ _ _ _._u_._._ _ ..__ 2 .. __.

...I.~.:::~~~::.~!~~.:!.~~:~..~.~.~.~~~.~~~.?.!..~.~..:.~~.~~~.~:.._ B.................. .. 4. .Joint Aspiration C 1

.......... _ ....•................... _ __ _ •._ .._ •..._ .._-_.------_.- _ _ _... .•..... -.._ _ ......•..... -..- ._.•--._-_.- ...••.._ _-

..:~~~~..!~!.:.:~~.~.~ _ 0. 1 .Lumbar Puncture A ~......_ _ _ __ ._ _ _.__ _ _.._ __ _.D. _ __ ~ _ .Motor Point Block •·..P~~a~·e~t~~·is · ·..· - · -- ·..·..· A · · ·..· ·_ z:· ·_ .

.._ _ _ _ _ _ _ _ _. __ ._ __ Ll... _ _ .Percutaneous Skin Testing A-.................._ _ _ _ {:.\ 2., .Phenol/Alcohol Nerve Block D 2...·p·i;~~;;;;~t..·~T·c~~·t;~·I..·iv-·u·~~··..-..·- ..-- ..--..· -_ _- _-r: - ;;;.-._.-

........__ _ __ _ __ .__ _ __ t:::\ _ ~ _ .Repair of Lacerations A 2-s·t~·ii~te"G·~·~·g·ji;~-Bio~k~..- · -- ..· -·..· · _ _..1\ _ ·_ ·-Z··_ ·

T;i·g·g·e·;p~i·~t..i·~je·;ti·;~·..·..· · ·..· · _·_·..·C· j .Spray and Stretch Techniques C: 1_ ........•.... -.-.....•..............•• _ _--_ ...•.....- _-_ .-.._- _ ....................•.............................................. _ .Manipulation Q,"·..EMG..Bi;;fe~·d·b·a·ck· · ·..·..- ·..· · · C · \ - .

OTHER

._-_ .._._--_ _.__ __ ._._._ _._ ..-----_ .._._.__ .._.._-._ __ _ .._._ _ _--_ __ _-..

...~~_~~.~!~.~~_~_:~.~~._.._ ___._.._.. . ___._.6. ._ __ '2.. _

_..__ ._--- .._-_._-' --_.--_.---_. __ .__ .. ---_.-------_.--. _._--

i CliNICIA v

As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician'slevel of experience, past performance and quality indicators (if renewing privileges) as related to

. requested privileges and agree that clinician's qualifications are appropriate. The followingindicators have been reviewed for reappointment.

Since the date of the last appointment, we have reviewed applicable information from thefollowing sources of quality data:

o Physician's Health & Mental Statuso Inpatient Attending Performanceo Morbidity and Mortality Reportso Blood Usage Reportso Drug Usage Reportso Infection Reportso Invasive/Non-Invasive Procedureso Medical Records Documentation

o Patient/Family Satisfactiono Sentinel Events/Risk Management Reportso Consultation Attending Performanceo Outpatient Clinical Practiceo Peer Review of Clinical Performanceo Other:

We find as follows:

~ePtable review with recommendation of ~pointment to the clinical staff .with clinical privileges as requested.

o Concerns noted on review with correctiv action plan in place with recommen-dation of reappointment to the clinical st ff with privileges as requested, butsubject to a review in _ months.

DATE

.;Iin_pri.pmR:04/11/97