DA Form 5440-9 Delineation of Clinical Privileges-Podiatry

DA Form 5440-9 - also known as the "Delineation Of Clinical Privileges-podiatry" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5440-9 - was last revised on February 1, 2004. Download an up-to-date PDF version of the DA 5440-9 down below or look it up on the Army Publishing Directorate website.

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DELINEATION 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. FACILITY
(Last, First, MI)
INSTRUCTIONS:
PROVIDER: Enter the appropriate provider code in the column marked "REQUESTED". Each category and/or individual privilege listed must
be coded. For procedures listed, line through and initial any criteria/applications that do not apply. Your signature is required at the end of
Section I. Once approved, any revisions or corrections to this list of privileges will require you to submit a new DA Form 5440.
SUPERVISOR: Review each category and/or individual privilege coded by the provider and enter the appropriate approval code in the
column marked "APPROVED". This serves as your recommendation to the commander who is the approval authority. Your overall
recommendation and signature are required in Section II of this form.
PROVIDER CODES
SUPERVISOR CODES
1 - Fully competent to perform
1 - Approved as fully competent
2 - Modification requested
2 - Modification required
(Justification attached)
(Justification noted)
3 - Supervision requested
3 - Supervision required
4 - Not requested due to lack of expertise
4 - Not approved, insufficient expertise
5 - Not requested due to lack of facility support/mission
5 - Not approved, insufficient facility support/mission
SECTION I - CLINICAL PRIVILEGES
Category I.
Treat routine conditions of the foot and work under the supervision of a privileged podiatrist who assumes full responsibility of the
provider's acts.
Requested Approved
Category I clinical privileges
Category II. Includes Category I.
Examine, diagnose, and treat conditions of the feet requiring skills acquired during post-residency specialty training. Consultations should
be used when there is doubt concerning the diagnosis or when there is evidence of systemic disease, as first manifested by pedal symptoms.
Requested Approved
Category II clinical privileges
Category III. Includes Categories I and II.
Includes Categories I and II. Board certified or eligible. Prevention, diagnosis and treatment of complications involving the foot, arising from
various systemic diseases, as well as the palliative and corrective treatment of local foot pathology.
Requested Approved
Category III clinical privileges
AREAS OF FOOT PATHOLOGY
Requested Approved
Requested Approved
a. General Practice
d. Foot Orthopedics
b. Foot Surgery
e. Podopediatrics
(1) Common Podiatric Surgical Procedures
f. Podogeriatrics
(Specify in list which follows)
g. X-Ray Services (Interpretation)
(2) Complex Reconstructive Surgery
(Specify in list which follows)
c. Podiatric Dermatology
COMMON PODIATRIC SURGICAL PROCEDURES
Requested Approved
SKIN
NERVES
a. Decompression (posterior tibial nerve)
a. Digital syndactylism
tarsal tunnel
b. Excision of cutaneous lesions, benign
b. Decompression sinus tarsi
c. Excision of soft tissue lesions, cysts
c. Excision of neuroma
d. Grafts (simple, rotational, pedicle flap)
e. Plastic revisions (forefoot)
TENDONS
f. Removal of foreign body
a. Capsulotomy, midfoot with or without
g. Toenail procedures
tendon lengthening
b. Excision of cyst, (extra or intra-
tendonous), foot
c. Percutaneous Achilles lengthening
DA FORM 5440-9, FEB 2004
PREVIOUS EDITIONS ARE OBSOLETE
Page 1 of 3
APD V1.00
DELINEATION 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. FACILITY
(Last, First, MI)
INSTRUCTIONS:
PROVIDER: Enter the appropriate provider code in the column marked "REQUESTED". Each category and/or individual privilege listed must
be coded. For procedures listed, line through and initial any criteria/applications that do not apply. Your signature is required at the end of
Section I. Once approved, any revisions or corrections to this list of privileges will require you to submit a new DA Form 5440.
SUPERVISOR: Review each category and/or individual privilege coded by the provider and enter the appropriate approval code in the
column marked "APPROVED". This serves as your recommendation to the commander who is the approval authority. Your overall
recommendation and signature are required in Section II of this form.
PROVIDER CODES
SUPERVISOR CODES
1 - Fully competent to perform
1 - Approved as fully competent
2 - Modification requested
2 - Modification required
(Justification attached)
(Justification noted)
3 - Supervision requested
3 - Supervision required
4 - Not requested due to lack of expertise
4 - Not approved, insufficient expertise
5 - Not requested due to lack of facility support/mission
5 - Not approved, insufficient facility support/mission
SECTION I - CLINICAL PRIVILEGES
Category I.
Treat routine conditions of the foot and work under the supervision of a privileged podiatrist who assumes full responsibility of the
provider's acts.
Requested Approved
Category I clinical privileges
Category II. Includes Category I.
Examine, diagnose, and treat conditions of the feet requiring skills acquired during post-residency specialty training. Consultations should
be used when there is doubt concerning the diagnosis or when there is evidence of systemic disease, as first manifested by pedal symptoms.
Requested Approved
Category II clinical privileges
Category III. Includes Categories I and II.
Includes Categories I and II. Board certified or eligible. Prevention, diagnosis and treatment of complications involving the foot, arising from
various systemic diseases, as well as the palliative and corrective treatment of local foot pathology.
Requested Approved
Category III clinical privileges
AREAS OF FOOT PATHOLOGY
Requested Approved
Requested Approved
a. General Practice
d. Foot Orthopedics
b. Foot Surgery
e. Podopediatrics
(1) Common Podiatric Surgical Procedures
f. Podogeriatrics
(Specify in list which follows)
g. X-Ray Services (Interpretation)
(2) Complex Reconstructive Surgery
(Specify in list which follows)
c. Podiatric Dermatology
COMMON PODIATRIC SURGICAL PROCEDURES
Requested Approved
SKIN
NERVES
a. Decompression (posterior tibial nerve)
a. Digital syndactylism
tarsal tunnel
b. Excision of cutaneous lesions, benign
b. Decompression sinus tarsi
c. Excision of soft tissue lesions, cysts
c. Excision of neuroma
d. Grafts (simple, rotational, pedicle flap)
e. Plastic revisions (forefoot)
TENDONS
f. Removal of foreign body
a. Capsulotomy, midfoot with or without
g. Toenail procedures
tendon lengthening
b. Excision of cyst, (extra or intra-
tendonous), foot
c. Percutaneous Achilles lengthening
DA FORM 5440-9, FEB 2004
PREVIOUS EDITIONS ARE OBSOLETE
Page 1 of 3
APD V1.00
COMMON PODIATRIC SURGICAL PROCEDURES
(Continued)
Requested Approved
Requested Approved
TENDONS
OSSEOUS
(Continued)
(Continued)
d. Plantar fascial release (Steindler,
(4) Retrocalcaneal exostosis
simple)(Endoscopic)
k. Correction of hallux valgus or bunion with
e. Repair of ruptured tendon (forefoot)
proximal or distal osteotomy
f. Tendon transfers (forefoot)
(1) Joint resection with implant
g. Tendon lengthening (forefoot)
(2) Arthrodesis (MTPJ, Lapidus)
h. Tenectomy or Capsulotomy
l. Ostectomy
(1) Lesser tarsals
(2) Metatarsals (distal, proximal)
OSSEOUS
a. Arthrodesis I-P Joint, M-P Joint, 1st
through 5th
FRACTURES AND DISLOCATIONS
b. Arthrodesis T-M Joint
a. Open reduction with or without fixation
c. Excision of accessory bone: including
(digits, metatarsals)
sesamoidectomy
d. Excision of bone cyst, benign
INFECTIONS
e. Hammer toe correction
a. Incision and drainage (deep, superficial)
f. Akin type bunionectomy
b. Debridement of osteomyelitic metatarsals
and phalanges
g. Keller type bunionectomy
h. McBride type bunionectomy
c. Partial digital amputation
i. Ostectomy: any forefoot bone
(1) Complete or partial excision of
AMPUTATION
metatarsal head 1st through 5th
a. Digital amputation
(2) Bone graft harvest from foot
b. Ray resection
j. Ostectomy: any midfoot or rearfoot bone,
c. Metatarsal amputation
(partial, complete)
d. Transmetatarsal amputation
(1) Complete or partial excision of
metatarsal head 1st through 5th with
implant
OTHER
(2) Excision of tarsal coalition
a. Ankle arthrotomy
(3) Heel spur with or without fascial
releases
COMPLEX RECONSTRUCTIVE SURGERY
Requested Approved
TENDONS
Requested Approved
FRACTURES AND DISLOCATIONS
a. Tendon transfers (rearfoot)
a. Open reduction, with or without fixation
(1) Tendon suspensions (Young), (Hibbs),
(1) Calcaneus-talus
(Jones): tenodesis
(2) Lesser tarsals
(2) Anterior/posterior tibial
(3) Flexor transfer (rearfoot)
AMPUTATION
(4) Peroneal transfer
a. Chopart amputation
b. Tendon lengthening/repair: midfoot/
b. Symes amputation
rearfoot
OTHER
a. Ankle arthroscopy (diagnostic/surgical)
OSSEOUS
b. Ankle arthroplasty (debridement,
a. Arthroereisis
non-prosthetic)
b. Osteotomy with or without fixation
c. Ankle stabilization procedure:
Tenoplastic/Ligamentoplastic
(1) Calcaneus - talus
c. Arthrodesis
d. Bone graft harvest from distal tibia/fibula
(1) Navicular-cuneiform
e. Cavus foot reconstruction procedures
(2) Midtarsal/subtalar
f. Clubfoot release/reconstruction
(3) Triple arthrodesis
g. Endoscopic procedure
h. Flatfoot reconstruction procedures
i. Gastrocnemius recession
DA FORM 5440-9, FEB 2004
Page 2 of 3
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COMPLEX RECONSTRUCTIVE SURGERY
(Continued)
Requested Approved
Requested Approved
OTHER
(Continued)
j. Microvascular procedure
n. Vertical talus release/reconstruction
k. Repair of ruptured tendo-achilles
l. Suspected malignant neoplasms of the
foot
m. Tendo-achilles, peroneus longus: Tendon
lengthening
COMMENTS
SIGNATURE OF PROVIDER
DATE
(YYYYMMDD)
SECTION II - SUPERVISOR'S RECOMMENDATION
Approval as requested
Approval with Modifications
Disapproval
(Specify below)
(Specify below)
COMMENTS
DEPARTMENT/SERVICE CHIEF
SIGNATURE
DATE
(Typed name and title)
(YYYYMMDD)
SECTION III - CREDENTIALS COMMITTEE/FUNCTION RECOMMENDATION
Approval as requested
Approval with Modifications
Disapproval
(Specify below)
(Specify below)
COMMENTS
COMMITTEE CHAIRPERSON
SIGNATURE
DATE
(Name and rank)
(YYYYMMDD)
DA FORM 5440-9, FEB 2004
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