Privilege Form - NP (Feb 2021).pdf

February 2021

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.

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 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 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 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

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

Toenail removal

Anoscopy

IUD removal

TG 116 Attachment D

February 2021

** 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 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.

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

Page 2 of 2TG 116 Attachment D