[] Sl'Iould have clinical privileges granted b\lt restricted as foil

Ju1. 1. 20 13 9 : 50 AM augusta pediatrics No.4801 P. 8

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[II {Clinical Privileges Update Form JNlVERSIT'Y I ·~!ViRGINI.A I

Heidi MarCinto'n Regional Primftry Care_UPG HEALTH ~'vsmM IL__~--------_~_,·

I have J'eviewed the pl'lvlleges previously granted to me and request the following cbanges to include any new therapies, proe-dures, or additional training nece$Sftl"), to perto"'n new pl'lvIleges I'equested. (Please Include supporrlng documentarlon to vel'1A)t ctunpetency):

New Pl'Jvjleges to be Added (please indicate category level aDd type of expel'lence)~

------~-.--~~----,-------------..---------.~.--.-~-

Current P.'lvUeges not to be Renewed:'"

-----------,-----~----~.---,- ---_.__..... _._-,­~----.-.-,~-...,..------------.-----------.,.-,,~~- ..--"'.-~--.--------------,~.----------.------..--, .. ----,-,,--..,~,"'--~--~

:"Pri,ilriie;riot'l:enewed II~';IOt"~po~f~daa being \'oluilt~rlly relliiq'ullhed Uilits. ihi. is doiie\Vbllc )''Oii.~ ~lIdt' il'l;'(sIl8t1tlonj 'ortln retllrn fornol eOlldutllllIlln blvtSli,calion Or f1roe~din&- rr pl'i\'I1~~$ arc 10 II~ r~parle(lll$ vaillftlarll, rtlhlQlIlsbcd ),011lmillie IIOilned lIBill'ttth"<! a tON'.r Iht repor' 10 be nled wlU, lilt NllliOnftl }>n\ctUlollel' J)lIlnbRnk.

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As the DJvlsion He.ad/Ql Llaisoll Bnd Dep.rlment ChAir/Medical D;I'ect()t', we have I-eviewed the above­named elinieiaA', level of experience, past performallce Rud quality indicators (if rel1ewing pl'ivileges) as related to l'tquested pl'Mlllges and agree that the aboY~ named cUnltian's qtlanftcalloDs are ap)lI·oprlftte. Since tho date of the last appointment, we IlIl1'e re'Yiewed applicable information l)'OIn the following sources of qmlty and utill2!ation dAta: . .

{'

We find 8$ OWS: i ~

[;. Acceptable review with rQoommcmdatlon of reappoIntment to the clinical $laffwlth clinical pflvllegeSIS ~ reque&ted \ ,~

[] Concerne noted on review with corrective Bytion plliln in plaoo with tecommendatlon of reappOl!'tlnent to the cllnlc~1 staff with prIvileges as requested, but subject to a G months,'

_____ ---7--1-' /1]?0_ DAft '1f­---,----------4~--DATE •

Sr. Asso e or Clinical Affairs Chief Mg<ii!::~I()fficer

/

Clinical Privileges Update Form ~q~.liJh~~Heidi Martinson Regional Primary Care HEALTH SYsTEM

. .....

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):

--_ ......._---_......._­

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; ior, 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-"'", .~ h~\ \\ ~-ltt@£.qry\Qj~VV~ .~--.----..-~~,---------.------........­

DATE CLINICIAN SIGNATURE

As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed 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 applicable information from the following sources of quality and utilization data: .

We find asJi>Hows: • ~Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as

requested

[J 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 follows:, _____________

DATE

t, M.D., MBA Sr. Associa n for Clinical Affairs Chief Medical Officer

Clinical Privilt~gesUpdate Form

Martinson Regional Primary Care

RSITY~ .•, IRGINIAIIII-iEALTH SYSTEl\1

I have reviewed the prlvlleges 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 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.

-----'-~ ~I--~ 1-=------- _DATE 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:

VVef~a~Hows: .~ Acceptable review wlth 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: _

DATE

DATE B'ElPAR'FM]iSJ>IT "II' Ill. SIGNATURE~~'~~~~LtRevised 31112006

Heidi Martinson Regional Primary Care

UJ>.JIVERSITY~~if(tVIRGINIA!ID.!!! HEALTH SYSTF..M

Clinlcal 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 Privlleges not to be Renewed:*

*Privileges not renewed are not reported as being voluntartly 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

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

DATE 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:

We f~ aSJ9116ws:L£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.

Should have clinical privileges granted but restricted as follows: _D

DATE

ATE

REQUEST FOR CLINICAL PRIVILEGES.. Department of Pediatrics

University of Virginia Health System

Name Hejdi E,VY\oy-nnSen MO Division PedlStnGsMedical School -\6Mf>\0 \..,L(\ \ VUt..b \:bj .S'cbo?\ of maJJ6.\I~r ofGraduation ZC::03

Residency/Fellowship Training:Institution Specialty Year

1. \l>1¥1 t\WJJt Sjskm P{'ciw.tyLC--s 2003 -26Dip

2. _

3. _

Board/Sub Board Certification:Specialty Year Certified

1. _

2. _

3. _

Admitting Privileges? DYes (gj No

PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLYASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU

~ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY?RACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFTBLANK.

. 1. MEDICAL " ": : "

''1 General Pediatric Privileges.The minimal requirement is completion of a Pediatric Residency in an accredited Pediatricresidency orocrarn and certification by the American Board of Pediatrics or equivalent.Subspecialty Privileges (all require General Pediatric Privileges).The minimal requirement is completion of an accredited subspecialty residency (orequivalent as approved by Division Head and Department Chair). within 2 years 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 catherization

./'---. privileges, evidence of formal instruction, performance of at least 10 cases1-. with supervision, and annual performance of >20 cases/year.

Neonatology (required for Neonatal Intensive Care Unit Attending)

1

·------ECMO (requires ECMO training and approval by ECMO Medical Director)Pediatric EndocrinolocvPediatric Hematology/Oncology

-------Bone marrow aspiration, biopsy, and harvest; hematopoietic stem cell- reconstitution: Requires performance of 7 procedures under supervision of

physician with these privileges.Pediatric AllercvPediatric Critical Care (required for Pediatric Intensive Care Attending)Pediatric NephrcloqvPediatric Rheurnatoloov and ImmunoloqyPediatric Infectious DiseasePediatric Gastroenterology

------Pediatric endoscopy, liver biopsyPediatric Pulmonology

----Pediatric bronchoscopyPediatric GeneticsDevelopmental/Behavioral PediatricsAdditional Privileges

-------Conscious sedation------Swan-Ganz catheter placement

DATE Clinician Signature''''-' .

Print Name:Jd£L.d '" t. vnarhn00D

Division Head Approval

New Appointment

I 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 following Division-based quality data:

2

Print Name Signature Date

Print Name Signature Date

Jepartment Credentials Committee

The Pediatric Credentials Committee has reviewed this application and quality data supplied byUniversity of Virqinia Health System and approves the requested privileges.

I have reviewed this application for clinical privileges and recommend appointment/re-appointment tothe Clinical Staff with the above described privileges.

'DA"'·e.<.. F,M:e.qP--r,f{l"M.P ~( D£e

Department Chair/Medical Director

Print Name ~ ftp p(A.. ~ e c: Signature

c1in_pri.pedR: 3/7/02

3