r-----.-- .'. '.'.J" Clinical Privileges Update Form · { XllUVERSITY

""" -q'VIRGINIACharles Durbin Deportment of Anesthesiology I

••._!-IEALTI'~ SYSTE~I 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 suppOlung documentation to verify competency):

New Privileges to be Added (please indicate category level and type of experience):

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Current Privileges not to be Renewed:'"

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l~priv'ieges·;~t ~;e~~w~d·~I:~ ~.~t1;~pol·t~d ~.~' bei;ig·;OI~i~ta~ii'y-reil~q~i;Jledu~ies~·ih~·i;'do;;;i~il~yo;;re'I;~d~'~'h;v~!itigftli;;~;-'· 'or,11I reful'R for not conducting 1111 Investigation or proceeding. Upl"lvlleges Ilre to be reported as vohmtarily reUnquished you will be potlfled Ilnd receive It copy of the report to be filed witll the National Practitioner Databank.

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As the Division Head/QI Liaison and Department Chair/Medical Director. we have reviewed the above­named cliniclan's level of experience, past performance and quality indicators (if ,'enewing privileges) as related to requested privileges aud agree that the above named c1inlciau's qualifications are appropriate. Since the dote of the. last appoiutment, we have reviewed applicable information from the following sources of qUility and utilization data:

We Ii.....~?lows: [ff Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as

requested

o Concerns noted on review with corrective actfon plan In place with recommendation of reappointment to the clinical staff with prlvlleges as requested. but subject to a review In __ months.

Should have clinical privileges granted but res~ricted as f~~____________

~!tf!I'v . . # L ~- Bogdanoff

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