Chiropractor__privilege_list_20160310.pdf

AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 and 1102.

PRINCIPAL PURPOSE: To define the scope and limits of practice for individual providers. Privileges are based on evaluation of the individual’s credentials and performance.

ROUTINE USE: Information on this form may be released to government boards or agencies, or to professional societies or organizations, if needed to license or monitor professional standards of health care providers. It may also be released to civilian medical institutions or organizations where the provider is applying for staff privileges during or after separating from the Air Force.

DISCLOSURE IS VOLUNTARY: However, failure to provide information may result in the limitation or termination of clinical privileges

INSTRUCTIONS

APPLICANT: In Part I, enter Code 1, 2, or 4 in each REQUESTED block for every privilege listed. This is to reflect your current capability. Sign and date the form and forward to your Clinical Supervisor CLINICAL SUPERVISOR: In Part I, using the facility master privileges list, enter Code 1, 2, or 4 in in each VERIFIED block in answer to each requested privilege. In Part II, check appropriate block either to recommend approval, to recommend approval with modification, or to recommend disapproval. Sign and date the form and forward the form to the Credentials Office.

CODES: 1. Fully competent within defined scope of practice.

2. Supervision required. (Unlicensed/uncertified or lacks current relevant clinical experience.

3. Not approved due to lack of facility support. (Reference facility master Strawman. Use of this code is reserved for the Credentials Function.)

4. Not requested/not approved due to lack of expertise or proficiency, or due to physical disability or limitation.

CHANGES: Any change to a verified/approved privileges list must be made in accordance with Service specific credentialing and privileging policy.

NAME OF APPLICANT NAME OF MEDICAL FACILITY

I Scope Requested Verified

P384471

The scope of privileges for Chiropractors includes evaluation, diagnosis, and treatment of Active Duty patients, referred from other providers, with disorders of the musculoskeletal system. Chiropractic treatment includes the use of spinal manipulative therapy and/or other forms of manual therapy on articulations and/or muscular, tendonous and ligamentous soft tissues of the body, with emphasis on the spinal column. The chiropractor may use other supporting forms of treatment, such as physical modalities, decompression, and therapeutic exercise. Perform routine manual and mechanical, osseous and soft tissue chiropractic procedures for non-axial neurologic and musculoskeletal disorders or complaints.

Diagnosis and Management (D&M) Requested Verified

P384483 Order orthotic devices, materials and appliances available through the MTF and commonly used in the chiropractic profession

P384485 Provide instruction/recommendations regarding hygiene, nutrition, exercise, life style changes, stress reduction, and modifications of ergonomic factors as they relate to chiropractic treatment

P389664 Order imaging studies in accordance with MTF policy P389666 Order diagnostic laboratory studies in accordance with MTF policy

P386000 Initiate, continue, and terminate temporary/limited duty profile in accordance with Service policy

P389662 Refer patients to other practitioners as appropriate P386002 Place patients on quarters in accordance with Service policy

Procedures Requested Verified

P384489 Utilize the therapeutic modalities of heat, cold, light, electricity, ultrasound, traction and other procedures as appropriate in patient treatment

Procedure Advanced Privileges (Requires Additional Training) Requested Verified P384487 Utilize the therapeutic modality of laser Other (Facility- or provider-specific privileges only): Requested Verified

SIGNATURE OF APPLICANT DATE

LIST OF CLINICAL PRIVILEGES – CHIROPRACTIC

DOD MPL, CHIROPRACTIC, GENERATED FROM CCQAS FOR USE BY AFMS, APR 2014 1

CLINICAL PRIVILEGES – CHIROPRACTIC (CONTINUED)

II CLINICAL SUPERVISOR’S RECOMMENDATION

RECOMMEND APPROVAL RECOMMEND APPROVAL WITH MODIFICATION RECOMMEND DISAPPROVAL

(Specify below) (Specify below)

STATEMENT:

CLINICAL SUPERVISOR SIGNATURE CLINICAL SUPERVISOR PRINTED NAME OR STAMP DATE

DOD MPL, CHIROPRACTIC, GENERATED FROM CCQAS FOR USE BY AFMS, APR 2014 2