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TRANSCRIPT
McDaniel Department of Pediatrics
U~-'lER.srrY••• tf,VIRGINIAII!!HEALTH SYsTEM
Clinical Privileges 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 net to be Renewed: *
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*Privileges Dot renewed are not reported as 'being voluntarily relinquished unless this is done while you are under investigation;.or, in return for notconducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you:will be notifiedandreceive acopyof the report to be filed with the National Practitioner.Databank,
, " ,
....... ~~NATVRE·. • .•DATE
As theDiv~sion lIead/QI Liaison and-Department Chair/M;edical Director, wehave reviewed the above-named clinician's level of experience.past performance and quality indicators (ifrenewing privileges) asrelated to requested privileges and agree thatthe above named clinician's qualifications are appropriate.Sjnce the date of.the last appointment, we have reviewed applicable information from the following sources ofquality and utilization data: " '
DATE
R.evue.d 3/112006
McDaniel Department of Pediatrics
U])'U\'ERSITY.~ o/\TIRGINIA!m!!! I-:Ir:.A.LTH SYs:mM
Clinical Privileges 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 he Renewed:*
. .*Privileges not renewed are not repor ted 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 [he report to be filed with the National Practitioner Databank.~ - . .~
DATE
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 ofqU~lity nd utilization data:
We tin as 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 requ sted, but subject to a review in __ months.
D Should have clinical privileges grante
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DATE
.iJATE DEPARTMENT CHAIR SIGNATURE
Revised 31112006
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/ Nancy
Clinical Privileges Update Form
McDaniel Department of Pediatricsif .'
I have reviewed the privileges previously granted to me and request the following changes:
New Privileges to be Added (please indicate category level and type of experience):
Current Privileges not to be Renewed:*
Fpri~il~g-;;~ot renewed ~;~ not ;:;p~;t;ctas bei;g·:;;;~ntariJy-;.-;ii;q-;;j;he~~les7this is'd.;;;;-;hii~Y~-~-a-;:;-;;;;ct~rinvcstigati~;lor, in return Cor not conductingan investigationor proceeding. If privilegesare to be reported as voluntarily relinquished youiwill be notified and receivea copyof the report to be filedwith the National Practitioner Databank.
~ 11 L{ I o fo ~~ A. (l",/)C"l. n-D-A-T-E~~-L~--~-------------------- ~~--------------------
As the Division HeadlQI Liaison and Department ChairfMedical 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 followingsources of quality and utilization data:.,'/---
Medication Utilization
Out and Inpatent Util~9,on1J;J CV
Inpatient Activity [;r:1i '0 p.,SCf''ipfi~
Blood Utilization r;g::{£t;:1- v A /,'c.e.rlt!
Patient Satisfaction ~EA[gffsF WIIf/,tfnC£-tSltffJe
Infection Control
Medical Record Documentation
Inpatient Costs
We find as fo ows:
Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges asrequested
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.
Should have clinical privileges gr-D
DATE
-C'vL-C~~DEPARTMENTCHAIR SIGNATURE
Revised 12128/05
Nancy
Clinical Privileges Update Form
McDaniel Department of Pediatrics
~-I have reviewed the privileges previously granted to me and request the following changes:
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 investigation or proceeding. If privileges are to be reported as voluntarily relinquished youwill be notified and recelve a copy of the report to be filed with the National Practitioner Databank.
DATE
As the Division Head/QI Liaison and Department ChairlMedicaI 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 followingsources of quality and utilization data:
110 Number: 633172
Outpatient Clinical PracticePatient/Family SatisfactionPhysician's Health & Mental Status
Inpatient Attending Performance
Medical Records ReportsSentinel Events/Risk Management ReportsInfection ReportsDrug Usage ReportsUnscheduled ReadmissionsMorbidity/Mortality Reports
We find as
Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges asrequested
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 r. str
I I bv/v~TE
DATERevisedlU/17/01
DEPARTMENT CHAIR SIGNATURE
Clinical Privileges Update Form
Nancy McDaniel Department of Pediatrics
I have reviewed the privileges previously granted to me and request the following changes: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;Jor, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you~wiil be notified and receive a copy of the report to be filed with the National Practitioner Databank.
DATE
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 of quality and utilization data:
10 Number: 633172
Outpatient Clinical PracticePatient/Family Satisfaction
Physician's Health & Mental StatusInpatient Attending PerformanceMedical Records ReportsSentinel Events/Risk Management ReportsInfection ReportsDrug Usage Reports
Unscheduled ReadmissionsMorbidity/Mortality Reports
~ as follows: .
U Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges asrequested
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 r iew in months.
o
DATE DEPARTMENT CHAIR SIGNATURERevisedlO/17/01
REQUEST FOR CLINICAL PRIVILEGESDepartment of Pediatrics
University of Virginia Health System
Name N O\.V\~ L. 0c.D C1.V) I ~1 " Division CCV\cL,o lOj\/Medical School UY"\\;'Q yS ) ht of- \j tVJ I viI 0.. Year ofGraduation lqB 3Residency/Fellowship Training:
Institution
1. UwcJti~~~Y\~2. \A.\C\\ ", at V IY;j)'I\,"l:\3. _
Specialty
Pt d \ C\1-v) c..sYear
Jj~3 -i9C6b[9 C}; Co - (9 8~
~
t9Cf I ) 19Y7
General Pediatric Privileges.X The minimal requirement is completion of a Pediatric Residency in an accredited Pediatricresidenc ro ram and certification b the American Board of Pediatrics or e uivalent.
X Subspecialty Privileges (all require General Pediatric Privileges). f'c...:Li cdYic..(a..\d.- ~on InVCl~\' Q.
The minimal requirement is completion of an accredited subspecialty residency (ore uivalent as a roved b Division Head and De artment Chair. within 2 ears forPediatric Cardiology
----- Pediatric diagnostic cardiac catheterizationIncludes right and left heart catheterization, angiocardiography, and balloonatrial septostomy, and myocardial biopsy. Requires pediatric cardiologycertification and performance of >30 cases/year.
-------Interventional pediatric catheterizationIncludes ballon valvuloplasty, ballon angioplasty, intracardiac andintravascular stent placement, and therapeutic vessel or defect occlusion.Requires pediatric cardiology certification, diagnostic cardiac catherizationprivileges, evidence offormal instruction, performance of at least 10 caseswith su ervision, and annual eriormance of >20 cases! ear.
Neonatolo re uired for Neonatal Intensive Care Unit Attendin
Board/Sub Board Certification:Specialty Year Certified
PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY~A.SSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU
ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLYPRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFTBLANK .
1._P-e.cL O\m~2. -"PC J). 0.tY1 c... COv\.d. '\ c>l'() '/ _
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. .. ' . I. MED"C'JlL _.' ,',:,.--' - -' .. :' '.'.'- . . ,.. '#-I.' ~ ~l' J •.: • .t~. :'''~' '. ..:s:~ ~ . ", ~ d t,: :, ~.'" " .
Admitting Privileges? ~Yes o No
l
~--------ECMO (requires ECMO training and approval by ECMO Medical Director)
Pediatric EndocrinologyPediatric Hematology/Oncology -
--------Bone marrow aspiration, biopsy, and harvest; hematopoietic stem cellreconstitution: Requires performance of 7 procedures under supervision ofphysician with these privileges.
Pediatric A!ler~yPediatric Critical Care (required for Pediatric Intensive Care Attending)Pediatric NephrologyPediatric Rheurnatoloov and ImmunologyPediatric Infectious DiseasePediatric Gastroenterology
------Pediatric endoscopy, liver biopsyPediatric Pulmonology
-------Pediatric bronchoscopyPediatric GeneticsDevelopmental/Behavioral PediatricsAdditional Privileges
------Conscious sedation-------Swan-Ganz catheter placement
311y/o~ Y) (Jj',\{~ vr\~~DATE U Clinician Signature
Print Name: N o..Y\ Lli1 1-~Mt.-)J V\ VI 1~f, . .
Division Head Approval
New Appointment
·1 have reviewed this request for clinical privileges and approve it based on the applicant's training andexperience,
Print Name Signature Date
Re-appointment
I have reviewed this request for clinical privileges and approve it based on my personal observation ofthe applicant's clinical performance and the follow'ng ivision-based quality data: .•. J ~ M
~ - Q ~"tI\ -"( c V W\ ."'/
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1'-··-~ow" 'i'
Print Name
Print Name
Department Credentials Committee
The Pediatric Credentials Committee has reviewed this application and quality data supplied byUniversity of Virginia Health System and approves the re ue d pr] ile
40w ~'I
Signature Date
Department Chair/Medical Director
I have reviewed this application for clinical privileges and recommend appointment/re-appointment tothe Clinical Staff with the above described privileges.
Print Name
clinyri.pedR:3f7102
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