DAFORMFILLABLE.COM | DA FORM 5441-21 Fillable – Army Pubs 5441-21 PDF – DA FORM 5441-21, titled “Evaluation of Clinical Privileges – Physical Therapy,” is a crucial document used within the Army Medical Department. This form, identified by its publication number DA FORM 5441-21, is specifically designed to assess and document the clinical privileges of physical therapists. Understanding its purpose, structure, and usage is essential for those involved in military healthcare services.
DA FORM 5441-21 – Evaluation Of Clinical Privileges – Physical Therapy
| Form Number | DA Form 5441-21 |
| Form Title | Evaluation Of Clinical Privileges – Physical Therapy |
| Form Date | 02/01/2004 |
| Form Proponent | TSG |
Overview of DA FORM 5441-21
Publication Details
- Pub/Form Number: DA FORM 5441-21
- Pub/Form Date: February 1, 2004
- Pub/Form Title: Evaluation of Clinical Privileges – Physical Therapy
- Pub/Form Proponent: TSG (The Surgeon General)
- Pub/Form Status: Active
- Prescribed Forms/Prescribing Directive: AR 40-68
- Security Classification: Unclassified
- Distribution Restriction Code: A – Approved for public release; distribution is unlimited
This form is only produced in electronic media, ensuring easy access and efficient distribution within the military healthcare system.
Purpose and Importance
Why DA FORM 5441-21 Matters
The Evaluation of Clinical Privileges form for physical therapy is a standardized tool used to ensure that physical therapists within the Army are qualified to perform their duties. It evaluates various competencies and skills, ensuring that all practitioners meet the required standards set forth by the Army Medical Department.
Privacy and Security
Given the sensitive nature of the information recorded, DA FORM 5441-21 requires a Privacy Act Statement as mandated by AR 340-21. This ensures that all personal data is handled in accordance with federal privacy regulations, safeguarding the confidentiality of healthcare providers’ evaluations.
Key Components of DA FORM 5441-21
Structure of the Form
DA FORM 5441-21 includes several sections that comprehensively evaluate a physical therapist’s clinical privileges. These sections assess:
- Core Competencies: Fundamental skills required for physical therapy practice.
- Specialized Skills: Advanced techniques and procedures that a therapist may be privileged to perform.
- Professional Performance: Overall assessment of the therapist’s professional behavior and clinical decision-making.
Using the Form
The form is filled out by a supervising authority within the medical department, who evaluates the therapist’s capabilities in each area. The evaluation is based on direct observation, peer reviews, and performance metrics.
How to Fill Out DA FORM 5441-21
Step-by-Step Guide
- Personal Information: Begin by entering the physical therapist’s personal details, including name, rank, and contact information.
- Evaluation Period: Specify the period during which the evaluation is conducted.
- Competency Ratings: Assess and rate the therapist’s competencies using the provided scale.
- Comments and Recommendations: Include any additional comments or recommendations for further training or certification.
- Signatures: The form must be signed by the evaluating authority and the therapist being evaluated.
Best Practices
- Accuracy: Ensure all information is accurate and reflective of the therapist’s performance.
- Completeness: Fill out all sections of the form to provide a comprehensive evaluation.
- Confidentiality: Handle the form with care to maintain the privacy of the therapist’s personal information.
Compliance and Distribution
Adhering to Regulations
DA FORM 5441-21 is governed by the prescribing directive AR 40-68, which outlines the policies and procedures for the evaluation of clinical privileges. Compliance with these regulations is mandatory to ensure standardized evaluations across the Army Medical Department.
Electronic Availability
The form is available electronically, allowing for easy distribution and access. The Pub/Form IDN 990001 and Pub/Form PIN 066552 are identifiers used to locate and manage the document within the Army’s administrative systems.
Conclusion
DA FORM 5441-21 – Evaluation of Clinical Privileges – Physical Therapy plays a vital role in maintaining high standards within the Army Medical Department. By providing a structured and comprehensive evaluation of physical therapists, it ensures that all practitioners are qualified and capable of delivering high-quality care. Proper understanding and usage of this form are essential for healthcare administrators and supervisors responsible for evaluating clinical staff.
For more information on accessing and filling out DA FORM 5441-21, refer to the prescribing directive AR 40-68 or contact your local Army Medical Department administrative office.
DA FORM 5441-21 Fillable – Army Pubs 5441-21 PDF DOWNLOAD
