DA Form 5441-13: General Surgery Clinical Privileges PDF

DA Form 5441-13: General Surgery Clinical Privileges PDF – US Army medical providers, surgeons, and credentialing staff rely on DA Form 5441-13 as a key document for assessing and granting clinical privileges in general surgery. This form ensures providers demonstrate the necessary competence for safe, high-quality patient care in military treatment facilities (MTFs).

What Is DA Form 5441-13?

DA Form 5441-13, titled Evaluation of Clinical Privileges – General Surgery, is a standardized U.S. Army form dated February 2004. It supports the evaluation of a provider’s ability to perform specific surgical procedures and manage patients in general surgery.

The Department of the Army uses this form under AR 40-68, Clinical Quality Management (with updates through 2009 RAR). It pairs with DA Form 5440 series forms for delineation of privileges. Department/Service Chiefs complete evaluations based on demonstrated patient management skills, technical proficiency, and outcomes.

Key purposes include:

  • Initial granting or renewal of clinical privileges.
  • Reappraisal during appointment or reappointment to the medical staff.
  • Documentation of competence across core and advanced general surgery procedures.

Download the official PDF here: DA Form 5441-13 PDF.

Who Uses DA Form 5441-13?

  • General surgeons (active duty, reserve, civilian) in Army MTFs.
  • Department Chiefs and evaluators in credentialing processes.
  • Credentials Committees for privileging decisions.
  • Providers transitioning between facilities or seeking re-privileging.

It applies to evaluations for moderate sedation, endoscopy, trauma management, laparoscopic procedures, and more specialized areas like thoracic or vascular surgery privileges.

Structure of DA Form 5441-13

The form is concise (typically 3 pages) and includes:

Section I – Provider Information & Evaluation:

  • Provider name, rank/grade, evaluation period (YYYYMMDD).
  • Department/Service and Facility.
  • Ratings for Category I–IV clinical privileges (Acceptable / Unacceptable / Not Applicable).
  • Specific General Surgery Privileges with approval codes from the corresponding DA Form 5440.

Core General Surgery Privileges (examples from the form):

  • Moderate sedation.
  • Diagnostic and therapeutic endoscopy (EGD, colonoscopy, bronchoscopy, etc.).
  • Head and neck procedures (thyroid, parathyroid, salivary glands, lymph node dissection).
  • Breast procedures (biopsies, mastectomies, axillary dissection).
  • Abdominal and GI operations (esophagus, stomach, bowel, biliary tract, liver, spleen, etc.).
  • Laparoscopic procedures (hernia repair, appendectomy, bariatric, anti-reflux).
  • Hernia repairs with prosthetics.
  • Trauma management and resuscitation.
  • Intensive care procedures (central lines, ventilators, etc.).
  • Pediatric general surgery (common elective and emergent cases).
  • Sentinel lymph node biopsy.
  • Use of electrocautery, lasers (with special requirements).

Additional sections cover General Thoracic Surgery and General Vascular Surgery privileges, such as arteriography, bypasses, lobectomies, and more.

Section II – Comments: Evaluators must explain any “Unacceptable” ratings. Comments feed into reappraisal and reappointment decisions.

Signatures: Evaluator (Department/Service Chief) and date required.

Instructions emphasize: Line through non-applicable items, use privilege approval codes, and base evaluations strictly on demonstrated competence.

How to Complete and Use DA Form 5441-13?

  1. Provider Inputs — Fill basic info (name, rank, period).
  2. Evaluator Assessment — Rate each privilege category and procedure. Reference training logs, case volumes, proctoring results, and outcomes.
  3. Documentation — Attach supporting evidence (e.g., case logs, board certification, proctoring reports) as needed for advanced privileges like lasers or percutaneous interventions.
  4. Review Process — Route through credentials function per AR 40-68. Unacceptable ratings require detailed justification and may lead to focused review or remediation.
  5. Renewal — Use during periodic reappraisal (typically every 2 years or as specified by MTF policy).

Tips for Success:

  • Ensure current board certification (American Board of Surgery or equivalent) or eligibility.
  • Maintain adequate case volume for core privileges.
  • Document specific training for restricted procedures (e.g., sentinel node biopsy, PTCA/stents).

Why This Form Matters in Army Medicine?

Clinical privileging protects patients and providers while maintaining readiness. DA Form 5441-13 standardizes evaluations, aligns with Joint Commission and DoD standards, and supports seamless care across military facilities. Proper use reduces risk, ensures compliance with AR 40-68, and facilitates high-quality surgical care for service members, families, and retirees.

  • AR 40-68 Clinical Quality Management (full regulation).
  • DA Form 5440 series for initial privilege requests.
  • Air Force/DOD general surgery privilege lists (for cross-service reference).

For the most current guidance, consult your MTF Credentials Office or the latest Army Publishing Directorate resources. Always use official forms from armypubs.army.mil.