RN Privileging Form.doc

Peace Corps Office of Volunteer Support PCMO Privileges: RN Peace Corps Office of Volunteer Support PCMO Privileges: RN, page 3 of 3

Privileges for Peace Corps Medical Officers – Registered Nurses 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 RN.

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

QUALIFICATIONS FOR PRIVILEGES

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

· Successful completion of a three year diploma or four year bachelor of science in nursing degree

· Valid clinical RN licensure

· Applicable knowledge and experience

CORE PRIVILEGES

Privileges included in the Core: ** Privileges that fall within the typical scope of a RN privileges include:

(** Please strike out non-proficient privileges)

· Patient assessment and triage

· Initiate life support when necessary

· Work collaboratively with a clinical advisor in-country re: clinical diagnoses and patient management

· 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

· Measure Height, Weight, Vital Signs

· Perform a general patient survey: overall status

· Basic wound care, suture removal, dressing change

· Focused physical exam appropriate to presenting complaints to provide information to the clinical advisor as well as these clinical skills:

· Peripheral venipuncture

· Whisper/Gross Hearing Test

· Gross Vision with Snellen Eye Chart

· PPD test placement and reading

· Stool for occult blood

· Urine dipstick

· Thick and thin malaria smear preparation

· Office testing of HIV, strep, mono, pregnancy using commercial kits

· Intravenous therapy for hydration and to administer medications under the presence of the clinical advisor

· Hematocrit

· Pulse oximeter and PEAK flow meter readings

· ECG tracings

· Urethral catheterization

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).

Bimanual Exam

Pap Smear

Punch and shave biopsy

Suturing minor lacerations

** 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 RN.

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 1 of 2 March 2012 Page 2 of 2