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, ~Clinical Privileges Update Form

DODald Mathes Department of Anesthesiology

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 ofexperience):

:pf N~L~

Current Privileges not to be Renewed:*

__/..,..,ri. N l\ L~

j*Prlvlleges not renewed are not reported as being voluntarily relinquished unless this Is done while you are under Investigation; or, In return for not eonduetlng an Investigation or proeeeding. If privileges are to be reported IS voluntarily relinquished you will be notiDed and reeeive a eopy of the report to be ftled with the National Praetitloner Databank.

~.t).4i1A~DATE CLINICIAN S NATURE'-'t(. ~

As the Division Head/QI Liaison and Department ChajrlMedical Director, we have revie~ed 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. Since the date of the last appointment, we have reviewed appHcable 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 folio

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DATE

DATE

Mathes Department of Anesthesiology

Clinic:alPrivileges 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: *

• •••• ~. R', '.-_~ ~ ',.,. _~_~- ".__ ~'A~~_' .--.' , •••••""" ···~·.·4··-~-__ -.A-· .~ '_.~_.·_·.·.· .. h~,.·.·.~·~~"·'~~_~' ',_,~,'. ,-_., .' ..•. V._, v __ .•_v.·~ ~ , _••_._,'__ " •••• ~,., ", ••.__ •__

*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 you

vill be notified and receive a copy of the report to be filed with the National Practitioner Databank.

-.---z.LI{LL~__ --- . _DATE ~-~---

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:

We find a~ows:~_V;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 reappointmentto the clinical staff with privileges as requested, but subject to a review in __ months.

Should have clinical privileges granted but restricted as fo

DATE

DATE

Revised 3J1I2006

Donald Mathes Department of Anesthesiology

"U..NI..VER.SIT'x ..I.••. (I/\TIRGINIr\HEALTH SYSTEJ\1

Clinical Privih!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):

./)'\ 0 C\t'\0 (10ciL

Current Privileges not to he Renewed:*

/)'\{) C i/'\IAII\~

*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.

_'s 13'-"'-'-J-=.o----'o\'--'i ~~ /J/I.4....IL Y4()DATE CLINICIAN SIGNATURE 4~

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:

We fl2r'S follows:Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges asrequested

D Concerns noted on re\liew 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 a

DATE

DATE

Revised 31112006

Donald Mathes Department of Anesthesiology

U~RSITY•• q;_VIRGINIA_ HEALTH SYsTEM

Clinical PriviIE~gesUpdate 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 he Renewed: * .

No c\'\ ~d'\~

*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 of the report to be filed with the National Practitioner Databank.

\- \"2.. -0 &DATE

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:

We find as follows:~ Acceptable review with recommendation of reappointment to the clinicalstaff 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 foil

[!}A"(v~ ~--------------~----------------------------

DATE ,

r~- __ ±Ut10gDATE

Revised 31112006

---<Privilege List for Clinical Staff08-Sep-OO DEPARTMENT OF ANESTHESIOLOGY

Name: ~o"""J...\J. -(\(\c..~(, 0,-0 1Date:

PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE;EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER ANAREAIN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULDBE LEFT BLANK

ACCORDING TO CATEGORY, ENTER A, B, OR C IN THE REQUESTED COLUMN NEXT TO THE LISTED PRIVILEGE:

A The applicant will not undertake patient m:mngemenUprocedure except in emergency.

B The applicant will occasionally manage patients or assist in management/perform the procedure/assist in the performance, Consultation will besought in the event of antlcipated or actual difficulties.

C The applicant will independently m:mage patients/perfonn the procetlure. The applicant would be expected to request consultation onlyoccasionally.

ACCORDING TO TYPE, ENTER 1, 2, OR 3 IN THE COLUMNS IN THE E}''PERIENCE COLUMN:Completed Formal Training Program.

2 Limited Experience - without formal training.

3 Extensive Experience - without formal tr:rilling.

UVA Outpatient Surgery Center Privileges ~es o No

. ~~----------~--------------------------~--------~--------~Privilege: .

CategoryRequested

TypeExperienc

Medical

AnesthesiaIPain

HemodynPain Consul

PainDiff.. Pain Man

Pain Man

Periop- UPostopera

Preoperati

Critical CareCritical C

lCU - UnNeonate iPIC intub

PIC sedati

GeneralPharmacologic Mgt

antic Support Consults (

tation a. ,Dx&Tx

.•.~ 2.agement - acute L \agement - chronic ~ -z...nrestricted med assess & mgt r: \tive Assess L \ve Assess '- \

are - Neurology . R L.restricted Care ~ Z.ntubation & mech vent (2... 1-..-ation & mech vent a. --z-on, pain control ~ ~

\Procedure

Ainvay Control

1

Category Type *Privilege: Requested Experienc

Manual assisted ventilation (BVM) c \Tracheostomy - percutaneous k '7~....

Anesthesia/Pain

AirwayM

AirwayM~Airway M

AirwayMAirwayMAnesthes

Anesthes

AnesthesAnesthes

Anesthes

Anesthes

AnesthesAnesthes

Anesthesi

Anesthesi

Anethesia.--------. Anethesia

Echocardi

Neuromus

NeuromuPainMgt

PainMgtPainMgtPain Mgt

PainMgt

PainMgtPain MgtPainMgtPain MgtSedation

Sedation

Sedation

Sedation

Sedation

Critical Care

Mechanical ventilation I----------------- --J

Emergency

CPR I__ C--_' __ \__ ----'

Endoscopic

gt - LMA insert & intubation, unrestricted (j \.--gt - trach intub., flex. fiberoptic assist V- Igt - tracheal intub., anesthetized pt L- \-gt - tracheal intubation, awake c- \-gt -Laryngeal mask airway insert, restrict c.: \

ia - local, epidural t" \ia - local, field block I Iia - local, injection L- \ia - local, major nerve block ('- \ia - local, spinal c_ Iia Administration <- tia Conscious c, \.

ia Intercostal Nerve Block c__ Ia Local , Ia, local - minor nerve block ., \- general, admin, for endotrach. intubat / \- general, administration- unrestricted - \/

.ography - intraoperative trans esophageal ;- "::tc. Blocking Agent - admin intubated pts ,. '\

seular Blocking Agent - admin, unrestricted / \- epidural, single shot or continuous " I- intrathecal/epid.caths, pump implant ~~ 2-

- intrathecal/epidural caths, long term r" I

- nerve blocks.

\r:- Neurolytic nerve blocks -A-

"'Z.- Opioid/local anesth, unrestricted 'L- \- PCA (pt. controlled anesthesia) C- \- Radiofrequence nerve ablation .~ "7

- spinal, single shot or continuous <:.-.. \- conscious - intubated pts c:.,.... \- conscious, non-intubated pts C- l- deep, intubated pts. '--- \- deep, non-intubated pts. '- \- IV, unrestricted C- \

2

'1

Privilege:Type ~Experienc

CategoryRequested

Bronchoscopy~~------------------------------------------~--------~--~~----~Vascular

Central Venous Catheter

Invasive Monitor. - arterial catheters

Invasive Monitor. - central venous catheterInvasive Monitor. - vascular, umestricted

\

DATE

As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the above-named clinician's level of experience and training as related to requested privileges and agree that theabove named clinician's qualifications are appropriate. Therefore, we r ommend the appintment to theClinical Staff with the clinical privileges as requested.

__ ---'lP {?-l ( ./7" (),,--sfcJ)

DATE RE

DATE

3