DA Form 5441-9 Evaluation of Clinical Privileges - Podiatry

DA Form 5441-9 or the "Evaluation Of Clinical Privileges - Podiatry" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 5441-9 - was last revised on February 1, 2004. Download an up-to-date DA Form 5441-9 down below in PDF-format or look it up on the Army Publishing Directorate website.

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EVALUATION OF CLINICAL PRIVILEGES - PODIATRY
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
(Last, First, MI)
(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
AREAS OF FOOT PATHOLOGY
a. General Practice
b. Foot Surgery
(1) Common Podiatric Surgical Procedures
(Specify in list which follows)
(2) Complex Reconstructive Surgery
(Specify in list which follows)
c. Podiatric Dermatology
d. Foot Orthopedics
e. Podopediatrics
f. Podogeriatrics
g. X-Ray Services (Interpretation)
COMMON PODIATRIC SURGICAL PROCEDURES
SKIN
a. Digital syndactylism
b. Excision of cutaneous lesions, benign
c. Excision of soft tissue lesions, cysts
d. Grafts (simple, rotational, pedicle flap)
e. Plastic revisions (forefoot)
f. Removal of foreign body
g. Toenail procedures
NERVES
a. Decompression (posterior tibial nerve) tarsal tunnel
b. Decompression sinus tarsi
c. Excision of neuroma
TENDONS
a. Capsulotomy, midfoot with or without tendon lengthening
Page 1 of 4
DA FORM 5441-9, FEB 2004
PREVIOUS EDITIONS ARE OBSOLETE
APD V1.00
EVALUATION OF CLINICAL PRIVILEGES - PODIATRY
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
(Last, First, MI)
(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
AREAS OF FOOT PATHOLOGY
a. General Practice
b. Foot Surgery
(1) Common Podiatric Surgical Procedures
(Specify in list which follows)
(2) Complex Reconstructive Surgery
(Specify in list which follows)
c. Podiatric Dermatology
d. Foot Orthopedics
e. Podopediatrics
f. Podogeriatrics
g. X-Ray Services (Interpretation)
COMMON PODIATRIC SURGICAL PROCEDURES
SKIN
a. Digital syndactylism
b. Excision of cutaneous lesions, benign
c. Excision of soft tissue lesions, cysts
d. Grafts (simple, rotational, pedicle flap)
e. Plastic revisions (forefoot)
f. Removal of foreign body
g. Toenail procedures
NERVES
a. Decompression (posterior tibial nerve) tarsal tunnel
b. Decompression sinus tarsi
c. Excision of neuroma
TENDONS
a. Capsulotomy, midfoot with or without tendon lengthening
Page 1 of 4
DA FORM 5441-9, FEB 2004
PREVIOUS EDITIONS ARE OBSOLETE
APD V1.00
UN-
NOT
CODE
COMMON PODIATRIC SURGICAL PROCEDURES
(Continued)
ACCEPTABLE
ACCEPTABLE
APPLICABLE
TENDONS
(Continued)
b. Excision of cyst, (extra or intratendonous), foot
c. Percutaneous Achilles lengthening
d. Plantar fascial release (Steindler, simple)(Endoscopic)
e. Repair of ruptured tendon (forefoot)
f. Tendon transfers (forefoot)
g. Tendon lengthening (forefoot)
h. Tenectomy or Capsulotomy
OSSEOUS
a. Arthrodesis I-P Joint, M-P Joint, 1st through 5th
b. Arthrodesis T-M Joint
c. Excision of accessory bone: including sesamoidectomy
d. Excision of bone cyst, benign
e. Hammer toe correction
f. Akin type bunionectomy
g. Keller type bunionectomy
h. McBride type bunionectomy
i. Ostectomy: any forefoot bone
(1) Complete or partial excision of metatarsal head 1st through 5th
(2) Bone graft harvest from foot
j. Ostectomy: any midfoot or rearfoot bone, (partial, complete)
(1) Complete or partial excision of metatarsal head 1st through 5th with implant
(2) Excision of tarsal coalition
(3) Heel spur with or without fascial releases
(4) Retrocalcaneal exostosis
k. Correction of hallux valgus or bunion with proximal or distal osteotomy
(1) Joint resection with implant
(2) Arthrodesis (MTPJ, Lapidus)
l. Ostectomy
(1) Lesser tarsals
(2) Metatarsals (distal, proximal)
FRACTURES AND DISLOCATIONS
a. Open reduction with or without fixation (digits, metatarsals)
INFECTIONS
a. Incision and drainage (deep, superficial)
b. Debridement of osteomyelitic metatarsals and phalanges
c. Partial digital amputation
AMPUTATION
a. Digital amputation
b. Ray resection
c. Metatarsal amputation
d. Transmetatarsal amputation
DA FORM 5441-9, FEB 2004
Page 2 of 4
APD V1.00
UN-
NOT
CODE
COMMON PODIATRIC SURGICAL PROCEDURES
(Continued)
ACCEPTABLE
ACCEPTABLE
APPLICABLE
OTHER
a. Ankle arthrotomy
COMPLEX RECONSTRUCTIVE SURGERY
TENDONS
a. Tendon transfers (rearfoot)
(1) Tendon suspensions (Young), (Hibbs), (Jones): tenodesis
(2) Anterior/posterior tibial
(3) Flexor transfer (rearfoot)
(4) Peroneal transfer
b. Tendon lengthening/repair: midfoot/ rearfoot
OSSEOUS
a. Arthroereisis
b. Osteotomy with or without fixation
(1) Calcaneus - talus
c. Arthrodesis
(1) Navicular-cuneiform
(2) Midtarsal/subtalar
(3) Triple arthrodesis
FRACTURES AND DISLOCATIONS
a. Open reduction, with or without fixation
(1) Calcaneus-talus
(2) Lesser tarsals
AMPUTATION
a. Chopart amputation
b. Symes amputation
OTHER
a. Ankle arthroscopy (diagnostic/surgical)
b. Ankle arthroplasty (debridement, non-prosthetic)
c. Ankle stabilization procedure: Tenoplastic/Ligamentoplastic
d. Bone graft harvest from distal tibia/fibula
e. Cavus foot reconstruction procedures
f. Clubfoot release/reconstruction
g. Endoscopic procedure
h. Flatfoot reconstruction procedures
i. Gastrocnemius recession
j. Microvascular procedure
k. Repair of ruptured tendo-achilles
l. Suspected malignant neoplasms of the foot
m. Tendo-achilles, peroneus longus: Tendon lengthening
n. Vertical talus release/reconstruction
DA FORM 5441-9, FEB 2004
Page 3 of 4
APD V1.00
UN-
UN-
NOT
NOT
CODE
CODE
COMPLEX RECONSTRUCTIVE SURGERY
(Continued)
ACCEPTABLE
ACCEPTABLE
ACCEPTABLE
ACCEPTABLE
APPLICABLE
APPLICABLE
OTHER
(Continued)
SECTION II - COMMENTS
(Explain any rating that is "Unacceptable".)
NAME AND TITLE OF EVALUATOR
SIGNATURE
DATE
(YYYYMMDD)
DA FORM 5441-9, FEB 2004
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APD V1.00
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