DAFORMFILLABLE.COM | DA FORM 5441-3 Fillable – Army Pubs 5441-3 PDF – DA FORM 5441-3, titled Evaluation Of Clinical Privileges-Internal Medicine, is a crucial document utilized within the U.S. Army Medical Department. This form plays a significant role in assessing the clinical competencies and privileges of internal medicine practitioners. Introduced on February 1, 2004, by the Office of The Surgeon General (TSG), this form remains active and is governed by AR 40-68.
DA FORM 5441-3 – Evaluation Of Clinical Privileges-Internal Medicine
| Form Number | DA Form 5441-3 |
| Form Title | Evaluation Of Clinical Privileges-Internal Medicine |
| Form Date | 02/01/2004 |
| Form Proponent | TSG |
Understanding DA FORM 5441-3
Purpose and Importance
The Evaluation Of Clinical Privileges form is designed to ensure that medical professionals in the field of internal medicine are qualified to perform their duties. The evaluation process involves a detailed assessment of the practitioner’s skills, experience, and ability to provide high-quality medical care. This helps maintain high standards within military medical facilities, ensuring patient safety and effective healthcare delivery.
Key Features of DA FORM 5441-3
DA FORM 5441-3 includes several critical elements:
- Pub/Form Number: DA FORM 5441-3
- Pub/Form Date: 02/01/2004
- Pub/Form Title: Evaluation Of Clinical Privileges-Internal Medicine
- Pub/Form Proponent: TSG (The Surgeon General)
- Pub/Form Status: Active
- Prescribing Directive: AR 40-68
The form requires a Privacy Act Statement in accordance with AR 340-21, ensuring the confidentiality of the information provided. Additionally, it is only available in electronic media, as indicated by footnote 42.
Structure and Usage
Sections of DA FORM 5441-3
The form is divided into several sections to comprehensively evaluate the practitioner’s clinical privileges. These sections typically include:
- Personal Information: Basic details about the medical professional.
- Professional Qualifications: Education, training, and certifications.
- Clinical Competence: Detailed evaluation of clinical skills and competencies.
- Peer Reviews: Input from colleagues and supervisors on the practitioner’s performance.
- Final Assessment: Overall evaluation and recommendations regarding clinical privileges.
Filling Out the Form
Accurately completing DA FORM 5441-3 is essential for a thorough evaluation:
- Personal Information: Enter the practitioner’s name, rank, and other identifying details.
- Qualifications: Provide detailed information about medical education, residency, and any specialized training.
- Clinical Competence: Assess various aspects of the practitioner’s ability to diagnose, treat, and manage internal medicine cases.
- Peer Reviews: Collect evaluations from peers to provide a well-rounded view of the practitioner’s capabilities.
- Final Assessment: Summarize the findings and provide a recommendation regarding the granting of clinical privileges.
Legal and Distribution Information
Privacy and Security
As per AR 340-21, the form requires a Privacy Act Statement to protect the information provided by the practitioners. The form is classified as UNCLASSIFIED, ensuring that there are no restrictions on its access based on security clearance.
Distribution and Availability
The distribution of DA FORM 5441-3 is unlimited, as indicated by the Dist Restriction Code A. This means it is approved for public release and can be freely distributed within the relevant military and medical communities.
Identification and Change Management
- Pub/Form IDN: 990001
- Pub/Form PIN: 066534
- Changes: Any changes to the form are documented and updated as needed to reflect current standards and requirements.
Conclusion
DA FORM 5441-3 is a vital tool in the evaluation of clinical privileges for internal medicine practitioners within the U.S. Army Medical Department. By ensuring that medical professionals are thoroughly assessed, the form helps maintain high standards of healthcare, ultimately benefiting both patients and the medical community. Adhering to the guidelines and correctly filling out the form ensures a comprehensive evaluation process, supporting the goal of delivering exceptional medical care in the field of internal medicine.
DA FORM 5441-3 Fillable – Army Pubs 5441-3 PDF DOWNLOAD
