clinical privileges update form - university of virginia · clinical privileges update form ... as...
TRANSCRIPT
Clinical Privileges Update Form
Pamela Mason Department of Medicine
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):
f\J
...---.... ---- ---- ---- -------~ ---~ ---~
Current Privileges not lAe Renewed:*
N.. ..... -' ....._-----
--- .. ...----~~--
i*Privileges not renewed are not reported as bei~g~~~I~;t~~iiy'~~li';q;i;h~d~;;i;;~this is done~;hii;y;;~~e~;d;~wi';~~;tig;ti~;;;··· lor. in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you twill be notified and receive a copy of the report to be filed with the National Practitioner Databank.
As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the above· named clinician's level of experience, past performance and quality indicators (if renewing privjleges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Sinc'*the date of the last appointment, we have reviewed applicable information from the following sources of".quality and utilization data:
We find as follows:
~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested
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.
Should have clinical privileges granted but restricted as follo:.:w::;s:;,:_"""'-=:-----------
DATE
.. DATE
Revised 3/112006
UN1YERsrrYl,'.'I_V1RGINIA iHF.ALTHSySTE~_j
Clinical Privileges Update Form. -'-,
cIa Mason Department of Medicine
I have reviewed the privileges previously granted to me and request the following changes to includeany new therapies, procedures, or additional training necessary to perform new privilegesrequested: (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:*
---~----------------------
-~Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation;r, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you
will be notified and receive a copy of the report to be filed with the National Practitioner Databank.
r;;)~\2\ (0DATE CLINICIAN SIGNATURE
As the Division Head/QI Liaison and Department Chair/Medical 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:
wefin~ws:L Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as
requested,---1
! 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: _
J-~~~/()
3/1!} 0
DATE
Revised 3/1/2006
-Pamela Mason Department of Medicine
L.· . J~TJ~VERSITY~?/ VIRGINli\I!!!! l1r~TH SYSTEM
Clinical Privil(~ges Update Form
I have reviewed the privileges previously granted to me and request the following changes to includeany new therapies, procedures, or additional training necessary to perform new privilegesrequested. (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:*
*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 lnvestigatlon or proceeding, If privileges are to be reported as voluntarily relinquished youwill be notified and receive a copy ofrne report to be filed with the National Practitioner Databank.
DATE I
As the Division Head/QI Liaison and Department ChairlMedical Director, we have reviewed the above-named clinician's level of expe:rience, 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~~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.
D Should have clinical privileges granted but restricted as follows: _
----'--~J7/ (j yDATE
;s/~Jog-•
DIVISION EAD/QI LIAISON SIGNATURE
DATE DEPARTMENT CHAIR SIGNATURE
Revised 311/2006
Request for Laser PrivilegesUniversity of Virginia Health System
I Division of: c:ecau;\~
Please check those types of lasers that you are requesting privileges for, and indicate typeof training/experience.
TYPE OF EXPERIENCE: 123
Completed Formal TrainingLimited Experience - without formal trainingExtensive Experience - without formal training
PRIVILEGES
Laser Privileges Requested Type of ExperienceLaser Surgery - ArgonLaser Surgery - CO2Laser Surgery - HolmiumLaser Surgery - KTPLaser Surgery - Pulsed CLaser Surgery - YagLaser Surgery - Lite Sheer
~fr"aVttdJ'c~\\0:b\ 'I Q;)Con-iv" Ia -i nY4 .3
Clinician's Signature
As Division HeadlQI Liaison and Department Chair, we have reviewed the above-namedclinician's level of experience and past performance as related to requested privileges andagree that the clinician's qualifications are appropriate.
~it/~~
~-;?-/' Department Chair
Date
/(~A1==Z £0
Date
,~ Please return completed form to Clinical Staff Office, Box 800547.
Rev 7/2003
December 6, 2007
Pamela Mason, MDUniversity of Virginia Hospital1215 Lee StreetHospital Expansion Bldg., 4th FloorCharlottesville, VA 22908
Dear Dr. Mason:
Thank you for participating in the Excimer Laser Lead Management Summit Training at Mount Sinai MedicalCenter in Miami, FL with Dr. Roger Carrillo and Dr. Laurence Epstein on December 4-5, 2007. Yousuccessfully completed this portion of the clinical application of the Spectranetics Cardiac Lead RemovalSystem or CLeaRS'"as part of your training on the use of the CVX-300®Excimer Laser System.
Your training in use of the SLSand CVX-300 Excimer Laser System includes per FDA labeling:
1. A didactic session on laser safety and physics;2. A didactic session on SLSand laser operation followed by a demonstration of the CVX-300;3. Observation of the removal of at least two leads with the SLSperformed by an experienced SLS
user.
Thank you for your continuing support of the Spectranetics Corporation and we look forward to working withyou soon. If you require any further information on your training, please contact me at 800-640-7525.
Sincerely,
~Jason BottiglieriNational Training and Education Manager
UNIVERSITYIiio/VIRGINIA"<. -l-IEALTH SYSTEM
(j;k~e\o>1:.~\C'cSr)
REQUEST FOR CLINICAL PRIVILEGESDepartment of Medicine
Name
qg -2C£J2-~~~~~~u-~+-~~ __ ~~~~~~~~~~~~~~~uu~~~
~~~~~~---.:l..~~~~~~~~~~/c---~vJ .
Year(s} of Certification
Admitting Privileges? ')zCyes o No
PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLYASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOUARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY
/-.PRACTICE. AHEAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT3LANK.
. . I..MEDICAL , .According to category, enter A, B or C in the REQUESTED column.
Category A
Category B
The applicant will not undertake patient management except in emergency.
The applicant will occasionally manage patients or assist in management. Consultation will besought in the event of anticipated or actual difficulties.
The applicant will independently manage patients. The applicant would be expected to requestconsultation only occasionally. .
Category C
According to type, enter 1, 2, 3 and/or 4 in the EXPERIENCE column.
Type 1
Type 2
Type 3
Type 4
Formal Internal Medicine Training Program
Formal Specialty Training Program
Limited Experience - without formal training
Extensive Experience - without formal training
.: -. - CATEGORY TYPEPRIVILEGES REQUESTED AREAS' REQUESTED EXPERIENCE
, _ - (A, BarC) (1,2,3 &/or4)ALLERGY AND CLINICAL IMMUNOLOGY Differential diagnosis and treatment
Asthma
Hay fever
Serum sicknessUrticaria
Other
• I I. MEDICAL (conf'd) .' '. Page 2
CARDIOVASCULAR DISEASES Differential diagnosis and treatment C. 2-Acute myocardial infarction c.. -z.
With shock c. ZWith arrhythmia C-With cardiac arrest c. 2.
Aortic and peripheral vascular 0 2Cardiac arrhythmias G 2Cardiac rehabilitation C z,Cardioversion - medical G ZCongestive heart failure z.Hypertension C Z.Myocarditis c. ZPericarditis 2-Rheumatic fever C- 2-Stable angina pectoris c..... Z-Unstable angina pectoris G 2Valvular heart disease GOther
CLINICAL PHARMACOLOGY Differential diagnosis and treatment
Drug reaction and overdose
Drug-related disorder
Other
CRITICAL CARE MEDICINE Differential diagnosis and treatment
Adult Respiratory Distress Syndrome
Drug interactions
GI bleeding
Infectious disease
Mechanical ventilation and weaning
Nutritional disorders
Sepsis
Other
ENDOCRINE AND METABOLIC DISEASES Differential diagnosis and treatment
Addison's disease
Aldosteronism
Cushing's syndrome
Diabetes Mellitus \NIOOM
IODM
With acidosis
Electrolyte and water balance
Male or female infertility~
;: '>r";" 7'" - ", ;-~ ",'">- .",:.- '. '.' --.. ,.'. ',', L MEDICAL' 'cont~l -. Page 3- - ""..: .•~ i - .~.' - - ~., - '. - . _ .' 'I . .
ENDOCRINE AND METABOLIC DISEASES
(cont'd)
Parathyroid conditions
Pheochromocytoma
Pituitary conditions
Thyroid conditions
Other
EMERGENCY MEDICAL SERVICES Differential diagnosis and treatment
Airway management
Cardiopulmonary resuscitation
Medical emergent care
Toxicology
Trauma
Other
GASTROINTESTINAL AND
HEPATOBILIARY DISEASES Cholecystitis
Differential diagnosis and treatment
Cirrhosis
With bleeding varices
Decompensated
Hepatitis
Malabsorption
Nutritional disorders
Pancreatitis
Peptic Ulcer
Bleeding
Regional ileitis
Ulcerative colitis
Other
GENERAL MEDICINE Differential diagnosis and treatment
Disease prevention
Health maintenance
Immunization
Other -
GERIATRIC AND REHABILITATIVE
MEDICINE
Differential diagnosis and treatment
Dementia
Stroke rehabilitation
Other
HEMATOLOGICAL AND ONCOLOGICAL
DISEASES
Differential diagnosis and treatment
Hemorrhagic diathesis
Leukemia
Lymphoma
Solid Tumors
Other leukocyte and red cell disordersOther _
i" .: . "": .' ~ MEDICAL (conf'dJ:."" "" : ".". "Page 4
INFECTIOUS DISEASES Differential diagnosis and treatment
Bacteremia
With shock
HIV infection
Infective endocarditis
Meningitis
Other
NEUROLOGICAL DISEASES Differential diagnosis and treatment
Convulsive states
Degenerative diseases
Demyelinating diseases
Parkinsonism
Stroke
Acute
Rehabilitation
Other
OCCUPATIONAL AND ENVIRONMENTAL
MEDICINE
Differential diagnosis and treatment
Asbestosis
Environmental diseases
Work-related injuries
Other
PSYCHOPHYSIOLOGIC DISEASES Differential diagnosis and treatment
Anxiety
Depression
Other
PULMONARY DISEASES Differential diagnosis and treatment
Emphysema
Pneumonia
Pneumothorax, spontaneous
Pulmonary infarction
Pulmonary insufficiency
Other
RENAL DISEASES Differential diagnosis and treatment
Acid-based disorders
Fluid and electrolyte imbalance
Nephritis
Nephrotic syndrome
Renal failure
Urinary tract infection
~,========================~=Ot:h:er~~~~~~~~~~~~~========~=========:J
· .. '., -.: ·..I.,MEDICAL (cont'dJ .'.' '., . PageS
RHEUMATOLOGIC DISESES.
VASCULITIS AND DISEASES OF
IMMUNOLOGIC ORIGIN
Differential diagnosis and treatment
Differential diagnosis and treatment
Drug eruptions
Exanthematous diseases
Other
Allograft malfunction
Bone marrow
Heart
Immunosuppression
Infectious disease
Kidney
Liver
Lung
Multiorgan transplantation
Nutrition
Pancreas
Other
Dermatomyositis
Gouty arthritis
Lupus erythematosus
Osteoarthritis
Periarteritis nodusa
Rheumatoid arthritis
Thrombophlebitis
Other
SKIN DISEASES
TRANSPLANT MEDICINE
.- .. - II ~ROCE.DURSS ..- ." -' .. . . . •. '•• "-" • ','". ~--" y. ' '. •• '
Category A
Category B
Category C
According to category, enter A, B or C in the REQUESTED column.
The applicant will not undertake the procedure except in emergency.
The applicant will occasionally perform or assist in the performance of the procedure. Consultation willbe sought in the event of anticipated or actual difficulties.
The applicant will perform the procedure. The applicant would be expected to request consultation only.occasionally.
Type 1
Type 2
Type 3
Type 4
According to type, enter 1,2,3 and/or 4 in the EXPERIENCE column.
Formal Internal Medicine Training Program
Formal Specialty Training Program
Limited Experience - without formal training
Extensive Experience - without formal training
ALLERGY AND CLINICALIMMUNOLOGY
Allergen immunotherapyHistamine provocation
•• , ',.. , , "J ',' "'.'" ' ' ' , , ' ' CATEGORY TYPEPRIVILEGES REQUEsTED,' .:', ,,>,~,':'~:',\' :::,'"( AREAS <':» REQUESTED EXPERIENCE
",' "" " , ">,~" , ':;;"','":\: ,:;:,';c :' ' . , ,:: ",. '. (A, B or C) , (1,2,3 &/or4)ALLERGY AND CLINICAL Intradermal skin testing
IMMUNOLOGY (cont'd) Percutaneous skin testing
Other
ASPIRATION PROCEDURES Arterial blood gas L, 2Bone marrow aspiration
Culdocentesis
Nasogastric (e,g. gastric analysis)
Joint aspiration
Lumbar puncture
Paracentesis
Thoracentesis C- IThyroid Nodule
Transtracheal aspiration
Other
INVSIVE CARDIOVASCULAR AICD insertion c. 2PROCEDURES Balloon pericardiotomy ~ Z
Balloon valvuloplasty
Coronary artherectomy A 2-Coronary stent placement r~ Z~.
Diagnostic cardiac catheterization C ZElectrophysiologic studies C 2-IABC A zIntrapericardial catheter placement C '2Laser angioplasty
Pericardiocentesis C 2-Permanent pacemaker insertion C. ZPTCA
Radiofrequency-catheter ablation C ZTemporary cardiac pacing CJ' ZOther
CRITICAL CARE MEDICINE Arterial cannulation c.... .~PROCEDURES Cardiopulmonary resuscitation C-- 2
Chest tube insertion ,~ \Endotracheal intubation A IMechanical ventilation 13. IPlacement of central IV lines G ZRight heart catheterization
( j ZThrombolysis C 7Transtracheal 02 cannula A I
~ Venous cutdown C- '2.Other
ENDOSCOPIC PROCEDURES Anoscopy
Bronchoscopy
Colonoscopy
EMG biofeedback
ERCP
Esophgaogstro-duodenscopy
Flexible siqrnoidoscopy
GI motility studies
Laryngoscopy
Nasal endoscopy
Proctoscopy
Small bowel enteroscopy
Other
NUCLEAR MEDICINE
PROCEDURES
Calculate thyroid treatment dose
Breath hydrogen test
C-14 breath test
Myocardial perfusion imaging
Radionuclide angiography
Radionuclide kidney profile
Other
Extracrariial cerebrovascularULTRASOUND PROCEDURES
Hepatobiliary
Peripheral arterial
Renal
Transesophagealecho
Transthoracic echo
Venous studies
Other
SURGICAL PROCEDURES Diagnostic laproscopy
Gastrostomy
Incision/drainage of abscesses
Repair of lacerations
Sphincterotomy
Tenkhoff catheter placement
Tracheostomy
Tube thoracostomy
Other
OTHER Ambulatory ECG (Holter) monitoring
Arteriovenous shunt placement
Biopsy
Bone
Bone marriow
Kidney
Liver
OTHER (cont'd) Biopsy (cont'd)
Pleural
Skin
Thyroid
Cannulogram or fistulagram
Cardiac stress testing
Cardiopulmonary stress testing
Cardioversion-electrical
2
Conscious sedation
Electrocardiography
Intercostal nerve block
Hemodialysis
Peritoneal dialysis
PICC line placement
Polysomnography
Pulmonary function testing
Sengstaken or Minnesota tube placement
Slit lamp exam
Tilt table test zTonometry
Use of conscious sedation
Trigger point injection
Vascular access declotting
Other
DATE CLINICIAN
As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician's level ofexperience and past performance as related to requested privileges and agree the clinician's qualifications areappropriate. We have reviewed supporting documentation submitted for "other" privileges requested by theclinician and have determined that documentation is adequate to verify competency.
W~d as follows:
Ef'Acceptable review with recommendation of appointment to the clinical staff with clinical privileges asrequested.o Acceptable with proctoring as documented by the Department Chair and/or Division Head/QI Liaison.
02/08/2007