NP_Privilege_Form.doc

Peace Corps Office of Health Services PCMO Privileges: NP/PA

Peace Corps Office of Medical Services

PCMO Privileges: RN, page 2 of 3

Privileges for Peace Corps Medical Officers-Certified Nurse Practitioner Name:

Please Print Your Name and Credentials Country

PRIVILEGES REQUESTED

· Core Privileges – Privileges to perform duties for conditions that fall within the typical scope of a NP or PA.

· Additional Privileges – Privileges to perform duties for conditions that fall outside of the typical scope of a NP.

QUALIFICATIONS FOR PRIVILEGES

To be eligible for core privileges, the NP applicant must meet the following qualifications:

· Successful completion of a master’s, post master’s or doctoral level nursing degree

· Valid clinical RN licensure

· Valid nurse practitioner licensure and certification

· Applicable knowledge and experience

CORE PRIVILEGES

Privileges included in the Core: **

Privileges that fall within the typical scope of a NP or PA practice include:

(** Please strike out non-proficient privileges)

· Patient triage

· Initiate life support when necessary

· Work collaboratively with a clinical advisor re: clinical diagnoses and patient management beyond scope of practice

· Maintain an adult immunization program

· Maintain current, complete clinical records in SOAP format

· 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 exam

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

· Wart removal on extremities

· Pelvic/Bimanual exam and Pap smear

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

· Serve as a clinical prescriber for PCMO-RNs

· Peripheral venipuncture for labwork 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

· Toenail removal

· Anoscopy

ADDITIONAL PRIVILEGES REQUESTED

To be eligible for a clinical privilege listed below, the applicant must demonstrate and/or document competence in performing the requested procedure(s).

** 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 PRACTITIONER:

I have requested only those clinical privileges for which, by education, training, current experience, and demonstrated performance, I am qualified to function as a Peace Corps Medical Officer and a NP or PA.

I understand that in conducting any clinical privileges granted, I am constrained by the Peace Corps Office of Health Services policies and rules.

Applicant Signature:

Please Sign Your Name Date

CLINICAL SERVICE RECOMMENDATION

Core Clinical Privileges Approved with modification(s) (specify below) Approved as requested

Denied

Additional Clinical Privileges

Approved with modification(s) (specify below)

Approved as requested

Denied

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 Health Services February 2013 Page 1 of 2 February 2013