UVA Medical Center,UVA Transitional Care Hospital

UVA Health South Rehabilitation Hospital

Privilege List for: Acute Care Nurse Practitioner25-Aug-JO

Namc:Pr\&.ott L-. {)"W':"S Date: 2-5'""~ ID

PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCYPRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DONOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK.

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

ProcedureProcedureProcedureProcedureProcedureProcedure

• =>, ProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedure

!

'------ -t-Ji~i':;w:t----tz-t3----f\--ci·'-P---a-+'---fr.j..-"'-O,.:lc~- c:~---- _L~~ -T-I:1tL~r-+\~~'----i

I

------------- ---- c=- ----C-----c--iI

------------I--c--- -L~- c-1ere 1L-- eelc " ri----------------------------=ts: --- L ---------------it> fJ 8 I

----- ------ -~-----f----------~----·,------l

A The applicant will not undertake patient management except in emergency.

8 The applicant will manage patients with physician present.

C The applicant will manage patients in collaboration and/or consultation with the physician.

Adjust Cardiac Assist DevicesAdjust Intra-Aortic Balloon Pump SettingsAdjust Pacemaker SettingsAdjustment of InfusionsAllergen ImmunotherapyAmbulatory Halux 02 SaturationAnesthesia - Nitrous Oxide AnalgesiaAnesthesia LocalAnesthesia RegionalAnoscopyArterial Blood GasArterial Blood Gas PunctureArterial line placementArterial Line RemovalArterial Sheath Removal -->4 in.ArthrocentesisAudiometryAV Fistula Sheath RemovalBone Marrow AspirationBreath Hydrogen TestCamino Bolt RemovalCentral Line Placement & Mgt,Central Venous Line PlacementCentral Venous Line RewireCerumen Impaction RemovalChemotherapy - PO/IV/IntrathecalChest Tubes - Clamp and/or RemoveChest Tubes - Insertion & MgtConscious SedationCPREar Wicks - Insert & RemoveEMGEMG BiofeedbackEndotracheal IntubationEpicardial Pacing Wire RemovalExtubation

C-- - C I----------------------------------------I--~--- --------------j

i

Page 1 of 5

UVA Medical Center,UVA Transitional Care Hospital

UVA Health South Rehabilitation Hospital

Privilege List for: Acute Care Nurse Practitioner25-Aug-lO

Name:

ProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedure

.---- ProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedure

~'" ProcedureProcedureProcedureProcedureProcedure

Foreign Body Removal - External auditoryForeign Body Removal - NasalForeign Body Removal - SubcutaneousForeign Body Removal- SubungualForeign Body Removal- VaginaFracture/Dislocations (Closed) Anterior ShoulderFracture/Dislocations (Closed) App Imrnobiliz DevFracture/Dislocations (Closed) Digital DislocationFracture/Dislocations (Closed) PatellarHansel Smear - Nasal SecretionsHistamine ProvocationIncision/Drainage of AbscessesInitiation of InfusionsInsert Transvenous PacemakerIntermittent Catheterization TxIntracardiac Catheter RemovalIntradermal Skin TestingIntubation & Mechanical VentilationIV Medications & Fluids - AdministrationJackson Pratt Drain RemovalLab Test - Blood Cultures - DrawLab Test - Cervical CulturesLab Test - Dipstick UrinalysisLab Test -Rectal CulturesLab Test - Soft Tissue Site CulturesLab Test - Throat CulturesLab Test - Urethral CulturesLab Test - Vaginal CulturesLumbar PunctureMediastinal Chest Tube RemovalMicroscope Eval - Breast DischargeMicroscope Eval - Post Coital Cervical MucousMicroscope Eval - UrineMicroscope Eval- Vaginal SecretionsNail Trephination/RemovalNeedle Biopsy of LiverOmaya ReservoirPAP SmearParacentesisPercutaneous Skin TestingPeripheral Central Venous Line PlacementPulmonary Artery Catheter PlacementPulmonary Artery Catheter RemovalPulmonary Function TestsRemove Transvenous PacemakerSigmoidoscopy

Date:

NeonatalPed Adol Adult Geriatric--------.--.~.--~}-f1-'A A PIA PI A

~. ;K I---.- .._._---- -'--- -- ._--- -_.__ .,I I

--.~---.----·--rh- ••• ---. ----·---1 j

f------- ---- -·-1J;--·i---i3-e-p:··-1r -r 7

.----.----,-.~-++iicl.-- ..iL_ - ..-.--.-/---c- ..-

1----- ---- ...-...-..-.-,-.-~'--I--;---l(/ C ( .

II :-.---..-- -·-JFf--·-I~-.-!

G- r C I

-.--------.-'-LPJ:--~c-~-Gp\ ft I A

f----f-··--··- j-"'-'1-8" ------.!OJ , G I

---.--1- .....---- --.--- ..---.-+11

--

1-.--------..-..-- --.~--e;---b--'I. i

Page 2 of 5

UVA Medical Center,UVA Transitional Care Hospital

UVA Health South Rehabilitation Hospital

Privilege List for: Acute Care Nurse Practitioner25-Aug-lO

Name:

ProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedureProcedure.~"rocedureProcedure.Procedure'ProcedureProcedureProcedureProcedureProcedureMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedical

-rr>: MedicalMedicalMedicalMedicalMedical

Slit Lamp ExamSpirometrySurgical AssistSurgical Drain RemovalThoracentesisTonometryTPN OrderingTracheostomy Tubes - RemoveTranstracheal AspirationTypanometryUrodynamic Studies - Percutaneous EMGUrodynamic Studies - Rectal Tube InsertionUrodynamic Studies - Simple Office CystometricsUrodynamic Studies - Urodynamic CatheterizationVenous Sheath RemovalVentriculostomy Catheter RemovalWound Mgt - DebridementWound Mgt - Assess for Functional IntegrityWound Mgt - ClosureWound Mgt - DressingWound Mgt - ElectrocoagulationWound Mgt - ImmobilizationWound Mgt - Removal of Sutures/StaplesWound Mgt - Wound preparationAllergy/immun Dif Dx & TxArterial Blood Gas InterpretationCardiac RehabCardiovascular Dif Dx & TxCholecystitisCirrhosisCNS InfectionsContraceptive CounselingCVA RehabDermatologic Diseases - Dx & TxDermatomyositisDiabetes MellitusDrug Reaction & OverdoseElectrolyte & Water BalanceEndocrine/Metabolic Dif Dx & TxGeneral Med Dif Dx & TxGeriatric Dif Dx & TxGouty ArthritisGynecologic Routine DifDx & TxHealth Maintenance & Disease PreventionHeme/One Dif Dx & TxHepatic Diseases Dif Dx & Tx

Date: -u: Au (J !0

Neonatal Ped Adol Adult GeriatricI

1---------. - -- ----r;- --~-- -C----

(/ C' Cab 1 6 I____. 12_. , . _

I .lIP e. p.,

-----------------~~ --~,~--f-'~--1I

----- -------J----- ---- --- --j

---------------ILt-- --~L-~r 00 ~~C §S C

--.-----t------- ------------. -- ~-------i r • C C

------f-------~~-_:t:---~r--Gee

--------------------'---i----~----I-t----JG C c

-----------------~-----t---~---Page 3 of 5

UVA Medical Center,UVA Transitional Care Hospital

UVA Health South Rehabilitation Hospital

Privilege List for: Acute Care Nurse Practitioner25-Aug-lO

Name:

MedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedical----------\1edicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalMedicalGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneralGeneral

_~ GeneralGeneralGeneralGeneralGeneral

Date: 1)7""~'J /0

Neonatal Ped Adol Adult Geriatric

------~----- '-7--- -1---- -7----1

/ C. (

HIV,AIDSICP Adjust Treatment ProtocolsImmunizationImpotence - Evaluation & MgtInfectious Disease Dif Dx & TxInfertility Initial Eval & MgtManagement of an emergency/precipitous deliveryNeurodegenerative DisordersNeurological DifDx & TxNutritional Status - Eval & MgtOsteoarthritisPain ManagementPancreatitisPituitary ConditionsPsychophysiologic Dif Dx & TxPulmonary Dif Dx & TxRenal Dif Dx & TxRenal failureRheumatic Fever - AcuteRheumatoid ArthritisRheumatologicNasc DifDx & TxSerum SicknessSpinal Shock - MgtThrombophlebitisUrologic Disease - DifDx & TxUrticariaVentilator Weaning MgtAdmissions (with MD collaboration)Dx, Assessment & MgtEvaluate - EchocardiogramEvaluate - EEGEvaluate - Holter MonitoringEvaluate - LabsEvaluate - RadiographsEvaluate - Urodynamic StudiesEvaluate Exercise Stress TestEvaluate Ultrasound StudiesHistory and PhysicalHospital RoundsOrder- ECGOrder - EchocardiogramOrder - EEGOrder - Holter MonitoringOrder - LabsOrder - RadiographsOrder - Urodynamic Studies

C r r--------------~-·G-----7--- ---~----c c. c I

GeeCr C. C

_______--- ..-~~-e--&:---i ~ __G c- G

( r C

-~~-=-~,~-;~~(/ G C' .•

----- "-'----"---'----7~---r--~--~G ( c. I

f---I----l--~ C e.-/17 b D

G G C-------I-·---I--I~---e:--(::-----r • L- r:

l- C Ie .--_.---._.-.-------.- _..-------.-,-·_---·--1--------\I

( C c.

Page 4 of 5

UVA Medical Center,UVA Transitional Care Hospital

UVA Health South Rehabilitation Hospital

Lh AvJ toNeonatal Ped Adol Adult Geriatric

------------L7----H-r---1C c..-- i ('

Privilege List for: Acute Care Nurse Practitioner25-Aug-IO

Name:Date:

General Order ConsultsGeneral Order Exercise Stress TestGeneral Order MedicationsGeneral Order Ultrasound StudiesGeneral Patient EducationGeneral Telephone Triage/Consultation

OTHER PRIVILEGES

___________+ ~----~-----L~i t > ? C

D};~fb)~I-! ------

--~ As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the above-named practitioner's level of experience, past performance and quality indicators (if renewing privileges) asrelated to requested privileges and agree that the above named practitioners qualifications-are appropriate.i.

~ ~d~----D.A~i2--~L,---[L_MV=-V~;g#Sfcian Signature Name Printed _s;:: --,LD~SJ1r0 C K ~~sY0

DATE

DATi~ 'L 5t1"'..._. .__q;,1l.-~ I __"

-,--~-f___IY--------

DATE~IJ~Il\l__ ~_DATE ~ Alternate Supervising tJhysician Signature

,~~

, / Dept Chair or Clinical AdministratorDATE

Name Printed

c..~Q.("\~ ~ {',.-Du..r- b~~Name Printed

Name Prlnted

.:'5 be,l.u 5"m.; +1-.:._'Name Printed- -':

Page 5 of 5