TG 116 Attachment D_NP Privilege_July 2024.pdf

TG 116 Attachment D July 2024 1

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:

(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/bimanual exam and pap smear

☐ 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 ☐ Simple laceration repair/I & D’s ☐ Tuberculin skin test placement and reading ☐ Wart removal on extremities ☐ Work collaboratively with a clinical advisor re:

clinical diagnoses and patient management beyond scope of practice

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

TG 116 Attachment D 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: NP

** 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