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EVALUATION OF CLINICAL PRIVILEGES - NURSE PRACTITIONER
For use of this form, see AR 40-68; the proponent agency is OTSG. 1. NAME OF PROVIDER (Last, First, MI) 3. PERIOD OF EVALUATION (YYYYMMDD) 5. FACILITY (Name and Address: City/State/ZIP Code) INSTRUCTIONS: Evaluation of clinical privileges is based on the provider's demonstrated patient managementabilities appropriate to this discipline, and his/her competence to perform the various technical skills and proceduresindicated below. All privileges applicable to this provider will be evaluated. For procedures listed, line through and initial any criteria/applications that do not apply. The privilege approval code (see correspondingDA Form 5440) will be entered in the left column titled "CODE" for each category or individual privilege. Those with an approval code of "4" or "5" will be marked "Not Applicable". Any rating that is "Unacceptable" must beexplained in SECTION II - "COMMENTS". Comments on this evaluation must be taken into consideration as part ofthe provider's reappraisal/renewal of clinical privileges and appointment/reappointment to the medical staff.
SECTION I - DEPARTMENT/SERVICE CHIEF EVALUATION
CORE PRIVILEGES
a. Provide primary and preventive care to the following categories of beneficiaries: (5) Women's Health (Uncomplicated obstetrical, postpartum, gynecological care) (1) Obtain relevant health and medical history (2) Perform physical examination based on age and history (3) Perform or order preventive and diagnostic procedures based on age and risks (4) Identify health and medical risk factors c. Diagnose acute and chronic health conditions and diseases (1) Formulate a differential diagnosis based on history, physical examination, and (2) Establish priorities to meet the health and medical needs of the individual, d. Develop and implement a treatment plan (1) Order, conduct, and/or interpret diagnostic laboratory and electrocardio- (2) Order radiographic and ultrasonic tests and procedures (3) Prescribe appropriate pharmacologic interventions (Note exceptions in the (4) Prescribe appropriate non-pharmacologic interventions (5) Provide relevant patient education or refer as appropriate (6) Refer and consult with other health professionals and community agencies (1) Determine effectiveness of treatment plan and document patient care (2) Reassess and modify plan as necessary to achieve health and medical goals DA FORM 5441-16, FEB 2004
SUPPLEMENTAL PRIVILEGES
a. Place patients in and release from observation status b. Admit and manage inpatient care for the following conditions (specify): PROCEDURES
b. Cryosurgery for dermatological growths e. Fitting of diaphragm for contraception g. Incision and drainage of abscess or cyst p. Waived testing of specimens (e.g., wet smear, microscopic exam, hemoccult, fingerstick blood glucose) IAW organizational guidelines SECTION II - COMMENTS (Explain any rating that is "Unacceptable".)
DA FORM 5441-16, FEB 2004

Source: http://www.armyreal.com/forms/pdf/A5441_16.pdf