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Page 1: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 2: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

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

Page 3: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 4: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 5: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 6: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 7: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 8: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 9: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 10: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 11: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 12: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 13: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 14: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 15: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 16: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 17: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 18: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 19: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 20: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 21: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 22: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 23: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 24: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 25: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 26: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 27: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 28: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 29: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION
Page 30: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

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

Page 31: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

-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

Page 32: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

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

Page 33: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

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

Page 34: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

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

Page 35: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

• 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~

Page 36: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

;: '>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 _

Page 37: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

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

Page 38: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

· .. '., -.: ·..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

Page 39: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

•• , ',.. , , "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

Page 40: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

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

Page 41: Clinical Privileges Update Form - University of Virginia · Clinical Privileges Update Form ... As the Division Head/QI Liaison and Department Chair/Medical Director, ... DIVISION

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