clinical.privucges update form - university of virginia · clinical.privucges update form lj...
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Clinical.PrivUcges Update Form lJ ERSI'I'Y ~? <'GINlA
Alexander Salomon RegionAl PrImary Care IW!!! IIFAcrH SYSTr~M
I have reviewed tIle privileges previously granted to me and I'cquest the following changes to include Blly llew theral)ies, procedut'es, or additional training necessary to perform new pl'ivileges requested. (Please include suppo.'Hug documentatiolt to verify competency):
New Pl'ivileges to be Added (please indicate category level aud type of experience):
CUJ'rentPl'ivilcge..~ not to he Renewed:'"
)"' ~". -, , , " '"'
·Pdvllegt'5I1ul r~lIewed 31'1)IIQI !"tporlcd R$ bellig volulllaril)' I'clinqulshctl uuIC~$ tiffs Ii dont' while )'Oll. are under Inv\~s(lgatiulii 01', III retum for 1101 condllClill1,: lin InvesflgRtlolI 01' IlNJtfootng. If privileges IU'I! 10 be I'epol'led lIsvohmlRrlly rellnqnlshcd you
II be notified Rnd receIve 1\ tOpy Q[ Ihe I'CPO!'t to be filed wttll the NII(\(llll\l ("rneIlUone,' Oailibank.
~ . "., .." CLINICIAN SIGNATURE
As Ute Division Head/QI Llalsoll and Department Chair/Medical Director, we have reviewed the abovenamed clinlchm's level of experience, past performance and quality indicators (if renewillg privileges) as related to ,'equested privileges and agree that the above named clinician's qualifications nre appropl'iate. Since the date of the last nllPoilltment, we bnve reviewed applicable information from the following sources of quality alld utilization data:
,f,
We f~ follows! . l~ Acceptable review with recommandatlon of reapPOintment to the clinieal etaff with clinical privileges ae
requested
[] Concerns noted on review with corrective actIon plan In place with reoommendatlon of reappointment to the clinical staff with privileges as requested, but subject to a review fl'l __ months,
Should have clinical prlVIlegos granted but restricted as follows: _____________
OATE
I>,\TE
Med, Dir., Regi
Jonathon Truwit, Sr. Associate Dean for Clinical Affairs ChietMJ~.(ji~aIOfficer
UVA Medica! Centerand
UVA Transitional Care Hospital
REQUEST FOR CLINICAL PRIVILEGESDepartment of Medicine
Residency Training Location and Years. C:L ~ .. aC~~(},eGtT()t~fI/ u Nt tJl;/4-1Tt rio.f f /tAL I 7j '-I - /177
Fellowship Training Location and Years1'.1/ Ir
Board Certification(s) inI A/'Tbf2-f/ A-L.- MY) I t{ ,V (;
Year(s) of Certification If q 1I ;J.() (J ?"UVA Outpatient Surgery Center D Yes ~o
Admitting Privileges? Medi al Center DYes ErN0
UVA ransitionalCare Hospital DYes (61\[0
PLEASE MARK AS REQUESTED ON Y THOSE AREAS WHERE YOU ARE REGULARLYASSIGNED TO PRACTICE; EMERGEN Y PRIVILEGES SHOULD BE MARKED WHERE YOUARE THE DESIGNATED PERSON TO C VER AN AREA IN WHICH YOU DO NOT REGULARLYPRACTICE. AREAS IN WHICH YOU 0 NOT REGULARLY PRACTICE SHOULD BE LEFTBLANK.
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, B or C) (1,2,3 &/or 4)
ALLERGY AND CLINICAL IMMUNOLOGY Differential diagnosis and treatmentAsthma C /Hay fever C__ /Serum sickness B 3Urticaria C /Other
Differential diagnosis and treatment
Acute myocardial infarction
With shock
With arrhythmia
With cardiac arrest
Aortic and peripheral vascular
Cardiac arrhythmias
Cardiac rehabilitation
Cardioversion - medical
Congestive heart failure
Hypertension
Myocarditis
Pericarditis
Rheumatic fever
Stable angina pectoris
Unstable angina pectoris IValvular heart disease
Other Ii
CLINICAL PHARMACOLOGY Differe tial diagnosis and treatment
Other
Drug re ction and overdose
Drug-r lated disorderI
CRITICAL CARE MEDICINE Differe tial diagnosis and treatment
Adult R spiratory Distress Syndrome
Drug in eractions
GI blee ing
Infectio s disease
Mechanical ventilation and weaning
Nutritional disorders
Sepsis
ENDOCRINE AND METABOLIC DISEASES Differential diagnosis and treatment~~~~~------------------------~--~-------r~--------~IAddison's disease
Other
Cushing's syndrome
Aldosteronism
Diabetes Mellitus
NIDDM
IDDM
With acidosis
Electrolyte and water balance
Male or female infertility
ENDOCRINE AND METABOLIC DISEASES
(cont'd)
Parathyroid conditions
Pheochromocytoma
Pituitary conditions
Thyroid conditions
Other
J
EMERGENCY MEDICAL SERVICES Differential diagnosis and treatment
Airway management
Cardiopulmonary resuscitation
Medical emergent care
Toxicology
Trauma
Other
GASTROINTESTINAL AND
HEPATOBILIARY DISEASES JDifferential diagnosis and treatment
Cholecystitis
Cirrhosis
ith bleeding varices
ecompensated
Hepatiti
Malabs rption
Nutritio al disorders
Pancre titis
Peptic leer
B eeding
Regional ileitis
Ulcerative colitis 3GENERAL MEDICINE
Other
Differential diagnosis and treatment
Disease prevention
Health maintenance
Immunization
Other
GERIATRIC AND REHABILITATIVE
MEDICINE
Differential diagnosis and treatment
Dementia
Stroke rehabilitation
Other
I(
HEMATOLOGICAL AND ONCOLOGICAL
DISEASES
Differential diagnosis and treatment
Hemorrhagic diathesis
Leukemia
Lymphoma
Solid Tumors
Other leukocyte and red cell disorders
Other
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 3Parkinsonism IStroke
Acute
Rehabilitation
I
Other
OCCUPATIONAL AND ENVIRONMENTAL
MEDICINE
Differential diagnosis and treatment
Asbestdsis
Environ ental diseases
Work-r lated injuries
Other
PSYCHOPHYSIOLOGIC DISEASES Differential diagnosis and treatment
Anxiety
Depression
Other~
PULMONARY DISEASES Differen~ial 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
Other
RHEUMATOLOGIC DISESES,
VASCULITIS AND DISEASES OF
IMMUNOLOGIC ORIGIN
Differential diagnosis and treatment
Dermatomyositis
Gouty arthritis
Lupus erythematosus
Osteoarthritis
Periarteritis nodusa
Rheumatoid arthritis
Thrombophlebitis
Other
SKIN DISEASES
TRANSPLANT MEDICINE
Differential diagnosis and treatment
Drug eruptions
Exanthematous diseases
Other
Allograft malfunction
Heart
Bone 'arrow
Immun suppression
Intectio s disease
Kidney
Liver..,.>Lung
....,)
Multior an transplantation
Nutrition
PancreasOther _
II. PROCEDURES
Category A
Category B
Category C
Type 1
Type 2
Type 3
Type 4
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 onlyoccasionally.
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 formqJ training
ALLERGY AND CLINICALIMMUNOLOGY
Allergen immunotherapyHistamine provocation
II. PROCEDURES (cont'd) Page 6
ALLERGY AND CLINICAL
IMMUNOLOGY (cont'd)
Intradermal skin testing
Percutaneous skin testing
Other
ASPIRATION PROCEDURES Arterial blood gas
Bone marrow aspiration
Culdocentesis
Nasogastric (e.g. gastric analysis)
Joint aspiration
Lumbar puncture
Paracentesis
Thoracentesis
Thyroid Nodule
Transtracheal aspiration
Other
INVASIVE CARDIOVASCULAR
PROCEDURES3
CRITICAL CARE MEDICINE
PROCEDURES
AICD insertion
Balloon pericardiotomy
Balloon valvuloplasty
Coronary artherectomy;
Coronary stent pi cement
Diagnostic cardia catheterization
IABC
Electrophysiologic studies
Intrapericardial ca heter placement
Laser angioplasty
Pericardiocentesi
Permanent pacemaker insertion
PTCA
Radiofrequency-catheter ablation
Temporary cardiac pacing
Cardiopulmonary resuscitation
Chest tube insertion
Endotracheal lntubation
Mechanical ventilation
Placement of central IV lines
Right heart catheterization
Thrombolysis
Transtracheal 02 cannula
Venous cutdown
Other
II. PROCEDURES (cont'd) Page 7
Anoscopy
Bronchoscopy
Colonoscopy
EMG biofeedback
ERCP
Esophgaogstro-duodenscopy
Flexible sigmoidoscopy
GI motility studies
Laryngoscopy
Nasal endoscopy
Proctoscopy
Small bowel enteroscopy
NUCLEAR MEDICINE
PROCEDURES
Other
Calculate thyroid treatment dose
Breath hydrogen test
C-14 breath test i
Myocardial perfusipn imaging
Radionuclide angi9graphy;
Radionuclide kidn~y profile
Other '
ULTRASOUND PROCEDURES Extracranial cereb ovascular
Hepatobiliary IPeripheral 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