MD_Privilege_Form.docx

Privileges for Peace Corps Medical Officers --Physicians Name: ______________________________________________________________________________ Please Print Your Name and Credential

PRIVILEGES REQUESTED (Please select one or both)

· Core Privileges – Privileges to provide treatment for conditions that fall within the typical scope of an MD or DO.

· Additional Privileges – Privileges to provide treatment for conditions that fall outside of the typical scope of a MD or DO.

QUALIFICATIONS FOR PRIVILEGES

To be eligible for core privileges, the MD or DO applicant must meet the following qualifications.

· Doctor of Medicine or Doctor of Osteopathy degree from a school in the United States or Canada approved by a recognized accrediting body in the year of the applicant’s graduation; OR

· A Doctor of Medicine or equivalent degree from a foreign medical school that provided education and medical knowledge substantially equivalent to accredited schools in the United States, plus Education Commission Foreign Medical Graduate (ECFMG) certification and/or graduation from a school listed in the Foundation for Advancement of International Medical Education and Research (FAIMER) http://www.faimer.org/resources/imed.html

· Validation of foreign medical school accreditation

· Valid clinical MD or DO licensure

· Applicable knowledge and experience

CORE PRIVILEGES

Privileges included in the Core:** Privileges that fall within the typical scope of a MD or DO practice include:

(**Please strike out any non-proficient privileges) Peace Corps Office of Medical Services PCMO Privileges: RN, page 2 of 3

· Patient triage

· Initiate life support when necessary

· Maintain an adult immunization program

· Maintain current, complete clinical records in SOAP

· Adhere to Peace Corps Medical Technical Guidelines

· Accompany medevacs when indicated

· Provide emotional support and short-term counseling

· Provide health education to Trainees/Volunteers

· Perform administrative functions of the health unit

· Accrue 20 or more hours of continuing education annually

· Perform comprehensive patient history taking and physical exams including pelvic exams/ pap smears

· Assess, diagnose, and manage acute and chronic clinical issues

· Toenail Removal

· Anoscopy

· Prescribe pharmacologic agents including controlled substances according to the Medical Technical Guidelines

· Serve as a clinical prescriber for PCMO-RNs

· Serve as a clinical advisor for PCMO-NPs or PAs

· Peripheral venipuncture for lab work and IV administration of meds

· PPD placement and reading

· Preparation of thick and thin malaria smears

· Pulse oximeter and PEAK flow reading

· EKG tracing and interpretation

· Office diagnostics including commercial testing kits for HIV, urine dips, HCG, etc.

· Basic microscopy including UAs, wet mounts, stool

· Uretheral catheterization

· Local infiltration anesthesia

· Simple laceration repair/I & D’s

· Punch/Excisional/Shave biopsy

· Needle aspiration for culture

· Wart ablation on extremities

Peace Corps Office of Volunteer Support PCMO Privileges: MD, page 2 of 2

ADDITIONAL PRIVILEGES REQUESTED

To be eligible for a privilege listed below, the applicant must be able to demonstrate and/or document competence in performing any requested procedure.

** On a separate sheet of paper, please describe any major, unexpected complications you have encountered for any of the Core Privileges or Additional Privileges you are requesting.

ACKNOWLEDGEMENT OF PRACTICIONER:

I have requested only those privileges for which, by education, training, current experience and demonstrated performance, I am qualified to perform, and that I wish to exercise as a Peace Corps Medical Officer and a MD or DO.

I understand that in exercising any clinical privileges granted, I am constrained by Peace Corps Office of Volunteer Support policies and rules applicable generally, and any applicable to the particular situation.

Applicant Signature: ______________________________________________ Date: ___________ Please Sign Your Name

CLINICAL SERVICE RECOMMENDATION:

Core Privileges Recommend Recommend with the following modification(s) and reason(s): _____________________________________ Denied Suspended Revoked

Additional Privileges Denied Recommend Recommend with the following modification(s) and reason(s): _____________________________________ I have reviewed the requested clinical privileges and supporting documentation for the above named practitioner and recommend action on the privileges as noted above:

Signature Date Chair, Credentialing Committee

Signature Date Medical Director, Office of Volunteer Support image1.jpeg