Privilege Form - MD (Feb 2021).pdf

TG 116 Attachment C Page 1 of 2

Privileges for Peace Corps Medical Officers-- Physicians

Name:

Please Print Your Name and Credentials Country

PRIVILEGES REQUESTED

Core Privileges – Privileges to perform duties that fall within 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)

Patient triage

Initiate life support when necessary

Maintain an adult immunization program

Maintain current and complete documentation of clinical care

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

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

Urethral catheterization

Local infiltration anesthesia

Simple laceration repair/I & D’s

Punch/Excisional/Shave biopsy

Needle aspiration for culture

Wart ablation on extremities

IUD removal

February 2021 http://www.faimer.org/resources/imed.html

Peace Corps Office of Health Services PCMO Privileges: MD/DO

February 2021 Page 2 of 2

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

ACKNOWLEDGEMENT OF PRACTICIONER

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 MD or DO.

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 as requested Approved with modification(s) (specify below) 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

Date Signature Medical Director, Office of Health Services or Designee

TG 116 Attachment C