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AHP Clinical Privileges Update Form

Christine Dubroff, FNP------- Department of Obstetrics and Gynecology

.I. have reviewed the privileges previously granted (copy attached) to me and request the following changes:New Privileges to be Added (please indicate category level and type of experience):

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~ AHP Clinical Privileges Update Form

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Privilege List for: Family Nurse Practitioner,~ 08-Feb-07

Name: Date:

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 PRNILEGE

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

B The applicant will manage patients with physician present.

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

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Neonatal Ped Adult GeriatricAdolAdjust Cardiac Assist DevicesAdjust Pacemaker SettingsAllergen ImmunotherapyAmbulatory Halux 02 SaturationAnesthesia LocalAnesthesia RegionalAnoscopyArterial Blood GasArthrocentesisAudiometryBiopsy - EndometrialBiopsy - VulvarBiopsyJRemoval - Skin LesionBone Marrow AspirationBreath Hydrogen TestCamino Bolt RemovalCardiac Arrest - AssistCerumen Impaction RemovalChemotherapy - POIIV!IntrathecalChest Tubes - Clamp and/or RemoveCircumcisionColposcopy - Cervical Biopsy/ECCCondyloma Tx'sConscious SedationCPRCryotherapyDiaphragm FittingDoppler Monitoring of FetusEar Wicks - Insert & RemoveEMGEMG BiofeedbackEndotracheal IntubationEpicardial Pacing Wire RemovalFetal MonitoringForeign Body Removal- Cornea/ConjunctivaForeign Body Removal - External auditoryForeign Body Removal - NasalForeign Body Removal - SubcutaneousForeign Body Removal - SubungualForeign Body Removal- Vagina

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Neonatal Ped Adol Adult GeriatricFracturefDislocations (Closed) Anterior ShoulderFracturefDislocations (Closed) App Immobiliz DevFracturefDislocations (Closed) Digital DislocationFracturefDislocations (Closed) PatellarHansel Smear - Nasal SecretionsHistamine ProvocationIncisionfDrainage of AbscessesIntermittent Catheterization TxIntracardiac Catheter RemovalIntradermal Skin TestingIUD Insertion & 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 PunctureMicroscope Eval - Amniotic FluidMicroscope Eval - Breast DischargeMicroscope Eval - Post Coital Cervical MucousMicroscope Eval - UrineMicroscope Eval - Vaginal SecretionsNail AvulsionNail TrephinationlRemovalNorplant Insertion & RemovalOmaya ReservoirOrtho Procedures - ClavicleOrtho Procedures - Lower ExtremitiesOrtho Procedures - NasalOrtho Procedures - Ribs - Stable ChestOrtho Procedures - Shoulder DislocationOrtho Procedures - Upper ExtremitiesPAP SmearParacentesisPercutaneous Skin TestingPeripheral Central Venous Line PlacementPessary Insertion & RemovalPulmonary Artery Catheter ManipulationPulmonary Artery Catheter RemovalPulmonary Function TestsSigmoidoscopySkin Laceration RepairSlit Lamp ExamSpirometrySurgical AssistSurgical Drain RemovalThoracentesisTonometryTPN OrderingTracheostomy Tubes - RemoveTranstracheal AspirationTypanometryUltrasound- Fetal Ltd AFIUltrasound - Fetal Ltd - Dating 1st TrimesterUltrasound - Fetal Ltd - Fetal Cardiac Activity

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Neonatal Ped Adol Adult GeriatricUltrasound - Fetal Ltd - Fetal PresentationUrodynamic Studies - Percutaneous EMGUrodynamic Studies - Rectal Tube InsertionUrodynamic Studies - Simple Office CystometricsUrodynamic Studies - Urodynamic CatheterizationVentricular Catheter RemovalWound Mgt - DebridementWound Mgt - Assess for Functional IntegrityWound Mgt - ClosureWound Mgt - DressingWound Mgt - ElectrocoagulationWound Mgt - ImmobilizationWound Mgt - Removal of Sutures/StaplesWound Mgt - Wound preparationAdjustment ProblemsAlIergylImmun DifDx & TxArthritisAttention Deficit DisabilitiesBirth Defects EvalCardiac RehabCardiovascular DifDx & TxCerebral PalsyCholecystitisCirrhosisCNS InfectionsCognitive RehabCongenital Heart DiseaseContraceptive CounselingCroup, epiglottitisCVARehabCystic fibrosisDermatologic Diseases - Dx & TxDermatomyositisDiabetes MellitusDialysis MgtDrug Reaction & OverdoseElectrolyte & Water BalanceEndocrinelMetabolic Dif Dx & TxFractures & DislocationsGeneral Med Dif Dx & TxGeneral Peds Dif Dx & TxGeriatric Dif Dx & TxGI Disease Dif Dx & TxGouty ArthritisGynecologic Routine Dif Dx & TxHead & Spinal Cord InjuryHealth MaintenanceHealth Maintenance & Disease PreventionHeme/One Dif Dx & TxHepatic Diseases Dif Dx & TxHIV,AIDSHyperbilirubinemiaICP Adjust Treatment ProtocolsImmunizationImmunodeficiencyImpotence - Evaluation & MgtInfectious Disease Dif Dx & TxInfertility Initial Eval & Mgt

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MalabsorptionManagement of an emergency/precipitous deliveryNephrotic Disease DifDx & TxNeurodegenerative DisordersNeurological Dif Dx & TxNewborn DifDx & TxNewborn screeningNutritional Status - Eval & MgtOB - High Risk Prenatal & Postpart Eval & MgtOB - Intermed. Risk Prenatal & Postpart Eval & MgtOB - Routine Prenatal & Postpart Eval & MgtOsteoarthritisPain ManagementPancreatitisPed Behavioral ProblemsPed Learning & language disabilitiesPed Mental retardationPediatric Emotional DisordersPituitary ConditionsPre & Post Op Cardiac CarePremature Disorders Dx & TxPremie Growth & DevelopmentPrenatal CounselingPsychophysiologic Dif Dx & TxPulmonary Dif Dx & TxRenal DifDx & TxRheumatic Fever - AcuteRheumatic Heart DiseaseRheumatoid ArthritisRheumatologicNasc DifDx & TxSerum SicknessSexual CounselingSpinal Shock - MgtThrombophlebitisUrologic Disease - DifDx & TxUrticariaVentilator Weaning MgtAdmissions (with MD collaboration)Dx, Assessment & MgtEvaluate - ECGEvaluate - EchocardiogramEvaluate - EEGEvaluate - Holter MonitoringEvaluate - LabsEvaluate - RadiographsEvaluate - Urodynamic StudiesHistory and PhysicalHospital RoundsOrder- ECGOrder - EchocardiogramOrder - EEGOrder - Holter MonitoringOrder - LabsOrder - RadiographsOrder - Urodynamic StudiesOrder ConsultsOrder MedicationsTelephone Triage/Consultation

Neonatal Ped Adol Adult Geriatric

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Neonatal Ped Adol Adult GeriatricOTHER PRIVILEGES

/- Z:Z--OrSignatureDATE Name Printed

DATE

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.

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