TG 116 Attachment C_Physician Privilege_July 2024.pdf

TG 116 Attachment C July 2024 1

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 World Directory of Medical Schools (https://search.wdoms.org).

• 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:

(Check all proficient privileges)

ESSENTIAL PRIVILEGES

Administrative

☐ Accompany medevacs when indicated ☐ Adhere to Peace Corps Medical Technical

Guidelines ☐ Maintain an adult immunization program ☐ Maintain current and complete documentation of clinical care ☐ Perform administrative functions of the health unit ☐ Provide health education to

Trainees/Volunteers Clinical and Procedures

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

☐ EKG tracing and interpretation ☐ Initiate life support when necessary ☐ Local infiltration anesthesia ☐ Office diagnostics including commercial testing kits for HIV, urine dips, HCG, etc.

☐ Patient triage ☐ Perform comprehensive patient history taking and physical exams including pelvic exams/ pap smears

☐ Peripheral venipuncture for lab work and IV administration of meds

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

☐ Provide emotional support and short-term counseling

☐ Pulse oximeter and PEAK flow reading ☐ Serve as a clinical advisor for PCMO-NPs ☐ Serve as a clinical prescriber for PCMO-RNs ☐ Simple laceration repair/I & D’s ☐ Tuberculin skin test placement and reading ☐ Wart ablation on extremities

Licensure ☐ Accrue 30 or more hours of continuing education annually

DESIRED PRIVILEGES

☐ Anoscopy ☐ Basic microscopy including UAs, wet mounts, stool ☐ IUD removal ☐ Needle aspiration for culture ☐ Preparation of thick and thin malaria smears ☐ Punch/Excisional/Shave biopsy ☐ Toenail removal ☐ Urethral catheterization https://search.wdoms.org/

TG 116 Attachment C July 2024 2

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 Chair, Credentialing Committee

Date

Signature Medical Director, Office of Health Services or Designee

Date

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

** 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