NP and PA Privileging Form.doc

Peace Corps Office of Medical Services

PCMO Privileges: RN, page 2 of 3 Peace Corps Office of Volunteer Support PCMO Privileges: NP/PA

Privileges for Peace Corps Medical Officers-Certified Nurse Practitioner or Physician Assistant Name: ____________________________________________________________________________ Please Print Your Name and Credentials

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 or PA.

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

· Successful completion of at least two years of pre-med college courses

· Successful completion of a certified physician-assistant program

· Valid clinical PA 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 Volunteer Support policies and rules.

Applicant Signature: ______________________________________________ Date: ____________________ Please Sign Your Name

CLINICAL SERVICE RECOMMENDATION

Core Clinical Privileges Denied

Recommend

Recommend with the following modification(s) and reason(s): _____________________________________________________ Additional Clinical 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 March 2012 Page 2 of 2