AF Form 22 Revised 2010.doc

CLINICAL PRIVILEGES EVALUATION SUMMARY

(Use additional paper, if necessary, to fully explain any comments)

1. NAME OF PROVIDER

2. SSAN

3. MTF

4. DEPARTMENT/SERVICE

5. PERIOD OF EVALUATION

FROM: TO:

6. PURPOSE OF EVALUATION [ ] RENEWAL ______Year

[ ] REASSIGNMENT/SEPARATION [ ] ADVERSE ACTION

7. ACTIVITY DATA (Cumulative for period of evaluation))

( ) OUTPATIENT VISITS ( ) INPATIENT/23 HOURS ( ) CPT CLINICIAL PROCEDURES

( ) ANESTHESIA CASES ( ) Total Surgical Cases ( ) DELIVERIES ( ) CONSCIOUS SEDATION PROCEDURES

8. LICENSE AND SPECIALTY CERTIFICATION

License: Expires: Waiver:

Certification: [ ] YES [ ] NO Expiration:

9. Advanced Life Support Certification: Mark N/A if not applicable.

BLS Expires: ACLS Expires: PALS Expires: NRP Expires: ATLS Expires:

Did any of the required advanced life support certification lapse without good cause during period of evaluation: [ ] NO [ ] YES (explain)

10. CME

Met CAT 1 and 2-CME? [ ] YES [ ] NO (explain)

Required AF Category 1: Category 2: 0 Total: (60 hours every 3 years if no other license requirement) Completed Category 1: Category 2: 0 Total:

11. HEALTH STATUS AND IMPAIRED PROVIDERS: (explain positives)

A. Are there any aspects of the provider's mental or physical health which may affect care for any of the requested privileges: [ ] NO [ ] YES

B. Has the practitioner displayed signs of a possible alcohol or other chemical dependence [ ] NO [ ] YES

12. APPRAISAL OF PRIVILEGES (As applicable, explain any patterns of care demonstrated through the following functions)

A. PEER REVIEW (Cumulative Data in PAF) # of Outpnt Recd Rev # of Inpnt/APV Recd Rev # Conscious Sedation Rev

# of Discrepancies # Discrepancies # Discrepancies

Comments:

B. PROCEDURES AND MORBIDITY & MORTALITY REVIEWS (Cumulative Data in PAF) # of OPERATIONS/PROCEDURES _____ TOTAL CASES REVIEWED: _____ COMPLICATIONS OF CARE:_ ___

# of Patient Deaths:________ # Standard of Care: Met ________ Not Met:_______

Explain all SOC Not Met:

C. RISK MANAGEMENT: (Cumulative Data in PAF) Number of Quality Improvement Reviews:___ ___ Standard of Care: ______Met _______ Not Met (explain)

Explain all SOC Not Met:

D. Infection Control:

Adverse findings based on occurrence or Infection Control Committee Findings: [ ] No [ ] Yes (explain)

E. PHARMACY AND THERAPEUTICS REVIEW

Medication Usage: Appropriate and within profile for Peer: [ ] Yes [ ] No

DUE DATA: [ ] YES [ ] NO CONCERNING TRENDS: [ ] NO [ ] YES (Explain)

F. Blood Products Utilization Review: ( Cumulative Data Maintained by Credentials and Placed in PAF)

Number of Units Transfused:______ ________

Identified by Pathology's Review Number of Opportunities for Improvement: __ _____ (explain any trends)

G. MEDICAL RECORDS (explain all negative comments)

Completes outpatient records correctly and in a timely manner [ ] YES [ ] NO Clarity/legibility of records: [ ] Satisfactory [ ] Not Satisfactory

Completes required Inpatient and Ambulatory Procedure Visits Records correctly and in a timely manner : [ ] Yes [ ] No [ ] N/A Inpatient Records Delinquency Rate: [ ] Meets standards [ ] Marginally Meets Standards [ ] Fails to Meet Standards Routinely

H. UTILIZATION REVIEW

Supervisory knowledge and record review demonstrate proper use of resources/supplies? [ ] YES [ ] NO (Explain) __________

I. ANCILLARY REVIEW (explain negatives).

Appropriate use of labs and ordering within norm of profile data for peers? [ ] YES [ ] NO [ ] N/A Appropriate use of radiology studies and ordering and within norm of profile data for peers? [ ] YES [ ] NO [ ] N/A Appropriate use of consultations and ordering within norm of profile data for peers? [ ] YES [ ] NO [ ] N/A

J. COMMITTEE and DEPARTMENTAL PARTICIPATION List ALL Committees Clinician is Assigned To and Comment on Participation

PROSTAFF: [ ] Superior [ ] Good [ ] Poor __________________ [ ] Superior [ ] Good [ ] Poor

Clinic and/or Flight: [ ] Superior [ ] Good [ ] Poor __________________ [ ] Superior [ ] Good [ ] Poor

_______________ [ ] Superior [ ] Good [ ] Poor __________________ [ ] Superior [ ] Good [ ] Poor

_______________ [ ] Superior [ ] Good [ ] Poor __________________ [ ] Superior [ ] Good [ ] Poor

AF Form 22, Dec 89 ECOMS Approved Overprint: 17 August 2010

EXEMPT FROM DISCOVERY UNDER 10 U.S.C. 1102

K. PATIENT & STAFF Satisfaction during evaluation period: (Data Maintained in PAF) Number of Favorable Communications and Letters:_______ Number of Validated Complaints in PAF Since Privileges Last Awarded: ___ ___ Overall Communication Skills: [ ] Satisfactory [ ] Not Satisfactory Are the Provider's interpersonal skills with both patients, staff and healthcare team acceptable? [ ] YES [ ] NO (explain)

I. Performance Evaluation: Circle

1. Basic Professional Knowledge Poor Fair Good Superior Not Observed

2. Professional Judgment Poor Fair Good Superior Not Observed

3. Demonstration of ethical standards in treatment Poor Fair Good Superior Not Observed

4. Maintenance of patient confidentiality Poor Fair Good Superior Not Observed

5. Sense of Responsibility Poor Fair Good Superior Not Observed

6. Ethical Conduct Poor Fair Good Superior Not Observed

7. Competence and Skill Poor Fair Good Superior Not Observed

8. History and Physical Exam Poor Fair Good Superior Not Observed

9. Record Keeping Poor Fair Good Superior Not Observed

10. Patient Management Poor Fair Good Superior Not Observed

11. Availability and thoroughness of patient care Poor Fair Good Superior Not Observed

12. Practice-Based Learning & Improvement Poor Fair Good Superior Not Observed

Ability to use scientific evidence and methods to investigate, evaluate and improve patient care practices.

13. Systems-Based Practice Poor Fair Good Superior Not Observed

Provider demonstrates both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care. This understanding has been evidenced by cooperative interaction with utilization and peer review activites, as well as medication management.

Other Comments Regarding Clinical Competence. ___________________________________________________________

FOR REAPPOINTMENT ONLY:

Recommendation for Reappointment: Upon observation of performance, judgment, and clinical skills during the past ___ years; review of all credentialing information available with particular focus on experience, current competence, and ability to perform the privileges requested; and relevant performance improvement and peer review information I recommend;

__ __ Reappointment and clinical privileges as requested.

_____ Reappointment and clinical privileges with the following reservations: ___________________________________

DATE

GRADE/NAME OF EVALUATOR

FORMCHECKBOX

NO FORMCHECKBOX

YES_______________________________

Provider Signature

AF Form 22, DEC 89, (Reverse) ECOMS Approved Overprint: 17 August 2010

EXEMPT FROM DISCOVERY UNDER 10 U.S.C. 1102