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