DA Form 5441-3 "Evaluation of Clinical Privileges - Internal Medicine"

What Is DA Form 5441-3?

This is a military form that was released by the U.S. Department of the Army (DA) on February 1, 2004. The form, often mistakenly referred to as the DD Form 5441-3, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 3-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;
  • Fill out the form in our online filing application.

Download an up-to-date printable DA Form 5441-3 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

ADVERTISEMENT
ADVERTISEMENT

Download DA Form 5441-3 "Evaluation of Clinical Privileges - Internal Medicine"

1023 times
Rate (4.6 / 5) 196 votes
EVALUATION OF CLINICAL PRIVILEGES - INTERNAL MEDICINE
For use of this form, see AR 40-68; the proponent agency is OTSG.
1. NAME OF PROVIDER
2. RANK/GRADE
3. PERIOD OF EVALUATION
(YYYYMMDD)
FROM
TO
4. DEPARTMENT/SERVICE
5. FACILITY
(Name and Address: City/State/ZIP Code)
INSTRUCTIONS: Evaluation of clinical privileges is based on the provider's demonstrated patient management abilities
appropriate to this discipline, and his/her competence to perform the various technical skills and procedures indicated
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 corresponding DA 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 be explained in SECTION II - "COMMENTS". Comments on
this evaluation must be taken into consideration as part of the provider's reappraisal/renewal of clinical privileges and
appointment/reappointment to the medical staff.
SECTION I - DEPARTMENT/SERVICE CHIEF EVALUATION
UN-
NOT
CODE
PRIVILEGE CATEGORY
ACCEPTABLE
ACCEPTABLE
APPLICABLE
Category I clinical privileges
Category II clinical privileges
Category III clinical privileges
Category IV clinical privileges
Medical Subspecialty
Allergy/Immunology
Cardiology
Endocrine and Metabolic Disease
Gastroenterology
Hematology/Oncology
Infectious Disease
Internal Medicine
Critical Care
Nephrology
Pulmonary Disease
Rheumatology
GENERAL INTERNAL MEDICINE PROCEDURES
a. Arterial puncture
b. Arthrocentesis
c. Bone marrow aspiration and biopsy
d. Central venous cannulation
e. Chest tube insertion
f. Moderate sedation
g. Electrocardiogram (ECG) interpretation
h. Electrocardioversion
i. Endotracheal intubation
j. Flexible sigmoidoscopy and biopsy
k. Fluoroscopy
l. Paracentesis
m. Pericardiocentesis (emergent)
n. Pulmonary function interpretation
o. Skin biopsy
p. Spinal tap
q. Thoracentesis
DA FORM 5441-3, FEB 2004
Page 1 of 3
PREVIOUS EDITIONS ARE OBSOLETE
APD V1.00
EVALUATION OF CLINICAL PRIVILEGES - INTERNAL MEDICINE
For use of this form, see AR 40-68; the proponent agency is OTSG.
1. NAME OF PROVIDER
2. RANK/GRADE
3. PERIOD OF EVALUATION
(YYYYMMDD)
FROM
TO
4. DEPARTMENT/SERVICE
5. FACILITY
(Name and Address: City/State/ZIP Code)
INSTRUCTIONS: Evaluation of clinical privileges is based on the provider's demonstrated patient management abilities
appropriate to this discipline, and his/her competence to perform the various technical skills and procedures indicated
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 corresponding DA 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 be explained in SECTION II - "COMMENTS". Comments on
this evaluation must be taken into consideration as part of the provider's reappraisal/renewal of clinical privileges and
appointment/reappointment to the medical staff.
SECTION I - DEPARTMENT/SERVICE CHIEF EVALUATION
UN-
NOT
CODE
PRIVILEGE CATEGORY
ACCEPTABLE
ACCEPTABLE
APPLICABLE
Category I clinical privileges
Category II clinical privileges
Category III clinical privileges
Category IV clinical privileges
Medical Subspecialty
Allergy/Immunology
Cardiology
Endocrine and Metabolic Disease
Gastroenterology
Hematology/Oncology
Infectious Disease
Internal Medicine
Critical Care
Nephrology
Pulmonary Disease
Rheumatology
GENERAL INTERNAL MEDICINE PROCEDURES
a. Arterial puncture
b. Arthrocentesis
c. Bone marrow aspiration and biopsy
d. Central venous cannulation
e. Chest tube insertion
f. Moderate sedation
g. Electrocardiogram (ECG) interpretation
h. Electrocardioversion
i. Endotracheal intubation
j. Flexible sigmoidoscopy and biopsy
k. Fluoroscopy
l. Paracentesis
m. Pericardiocentesis (emergent)
n. Pulmonary function interpretation
o. Skin biopsy
p. Spinal tap
q. Thoracentesis
DA FORM 5441-3, FEB 2004
Page 1 of 3
PREVIOUS EDITIONS ARE OBSOLETE
APD V1.00
UN-
NOT
CODE
PROCEDURE/SKILL
ACCEPTABLE
ACCEPTABLE
APPLICABLE
GENERAL INTERNAL MEDICINE PROCEDURES
r. Treadmill stress tests
ADDITIONAL GASTROENTEROLOGY PROCEDURES
a. Colonoscopy - diagnostic and therapeutic
b. Diagnostic ERCP
c. Therapeutic ERCP
d. Esophageal dilation
e. Esophageal manometry
f. 24-hour pH study
g. Esophagogastroduodenoscopy - diagnostic
h. Esophagogastroduodenoscopy - therapeutic
i. Liver biopsy
j. Percutaneous endoscopic gastrostomy
ADDITIONAL CARDIOLOGY PROCEDURES
a. Cardiac catheterization
b. Intraaortic balloon pump insertion
c. Transesophageal echocardiography
d. Transthoracic echocardiography
ADDITIONAL HEMATOLOGY/ONCOLOGY PROCEDURES
a. Cisternal tap
b. Prescription and administration of chemotherapy and biological therapy by IV, SQ,
IM, IT, and intracavitary routes
c. High dose chemotherapy with stem cell rescue, autologous and allogeneic
ADDITIONAL PULMONARY PROCEDURES
a. Bronchoscopy
b. Lung biopsy
c. Pleural biopsy
ADDITIONAL ALLERGY PROCEDURES
a. Rhinoscopy
ADDITIONAL ICU PROCEDURES
a. Arterial cannulation
b. Pulmonary artery catheterization
c. Transvenous temporary pacing
d. Ventilator management
ADDITIONAL ENDOCRINOLOGY PROCEDURES
a. Thyroid biopsy
Page 2 of 3
DA FORM 5441-3, FEB 2004
APD V1.00
UN-
NOT
CODE
PROCEDURE/SKILL
ACCEPTABLE
ACCEPTABLE
APPLICABLE
OTHER PROCEDURES
SECTION II - COMMENTS
NAME AND TITLE OF EVALUATOR
DATE
SIGNATURE
(YYYYMMDD)
Page 1 of 2 Pages
Page 3 of 3
DA FORM 5441-3, FEB 2004
APD V1.00
Page of 3