DA Form 5440-54: Thoracic Surgery Clinical Privileges PDF 

DA Form 5440-54: Thoracic Surgery Clinical Privileges PDF  – DA Form 5440-54 is the official U.S. Army form used for Delineation of Clinical Privileges in Thoracic Surgery. It enables qualified physicians to request and gain approval for performing specific thoracic surgical procedures in military medical treatment facilities (MTFs).

This form falls under AR 40-68 (Clinical Quality Management), with the Office of The Surgeon General (OTSG) as the proponent agency. The current version is dated February 2004 and remains available through official Army publishing channels.

Download the Official DA Form 5440-54 PDF

Note: Always use the official Army source for compliance. Forms must be completed per current AR 40-68 guidance.

What Is Thoracic Surgery Privileges Delineation?

Thoracic surgery focuses on the surgical treatment of diseases and trauma involving the chest wall, lungs, trachea, esophagus, mediastinum, and diaphragm. Privileges cover preoperative evaluation, operative management, and postoperative care, including trauma to the thorax.

In the U.S. Army Medical Corps, delineation of privileges ensures providers demonstrate competency for specific procedures. This process protects patients and maintains high standards in military healthcare.

Key Sections of DA Form 5440-54

The form uses a standardized coding system for requests and approvals:

Provider Codes (Requested column):

  • 1: Fully competent
  • 2: Modification requested (with justification)
  • 3: Supervision requested
  • 4: Not requested (lack of expertise)
  • 5: Not requested (lack of facility/mission support)

Supervisor Codes (Approved column): Similar scale for recommendations.

Main Privilege Categories

Endoscopy:

  • Bronchoscopy (flexible/rigid)
  • Esophagoscopy (flexible/rigid)
  • Laryngoscopy
  • Mediastinoscopy
  • Thoracoscopy (VATS)
  • EGD, Colonoscopy, Sigmoidoscopy

Minor Procedures:

  • Thoracentesis
  • Tube thoracostomy
  • Pleural biopsy
  • Tracheotomy
  • Needle biopsy of lung
  • Others (esophageal dilatation, drainage of abscess, etc.)

Lungs:

  • Thoracotomy
  • Lobectomy
  • Pneumonectomy
  • Wedge/segmental resection
  • Pleurectomy/pleurodesis
  • Decortication
  • Reduction pneumoplasty

Chest Wall:

  • Tumor resection
  • Thoracoplasty
  • Repair of pectus deformities
  • Sternal procedures

Trachea, Mediastinum, Esophagus, Diaphragm:

  • Trauma repairs
  • Tumor resections/excisions (e.g., thymectomy)
  • Anti-reflux procedures
  • Esophagectomy
  • Hiatal hernia repair
  • Diaphragmatic procedures

Laser Privileges (Argon, Nd:YAG, CO2):

  • Airway restoration
  • Pulmonary tumor treatment (requires additional training documentation)

The form includes sections for provider signature, supervisor recommendation, and credentials committee approval.

Who Needs DA Form 5440-54?

  • Active Duty Army Thoracic Surgeons
  • Civilian providers working in Army MTFs
  • Residents/Fellows seeking supervised or full privileges
  • Providers transferring between facilities or updating credentials

Similar forms exist across military branches and civilian hospitals, but DA 5440-54 is specific to Army processes.

How to Complete DA Form 5440-54?

  1. Provider Section: Enter name, rank, facility. Code each privilege in the “Requested” column.
  2. Supporting Documentation: Attach case logs, training certificates, board certifications (e.g., American Board of Thoracic Surgery), and proctoring records as required.
  3. Supervisor/Department Chief Review: Recommendations go in the “Approved” column.
  4. Credentials Committee: Final approval with possible modifications.
  5. Laser Privileges: Submit proof of formal training and MTF laser policy acknowledgment.

Revisions require a new form submission. Line through inapplicable items and initial them.

Importance in Military Medicine

Accurate privilege delineation supports:

  • Patient Safety — Matching provider skills to procedures
  • Readiness — Ensuring surgeons maintain skills for deployment
  • Compliance — Meeting Joint Commission and Army regulatory standards
  • Quality Improvement — Through ongoing professional practice evaluation (OPPE/FPPE)

Thoracic surgeons in the military often handle complex cases involving trauma, lung cancer, esophageal disorders, and congenital issues, making precise privileging critical.

  • AR 40-68: Clinical Quality Management (Army Regulation)
  • DA Form 5440 series for other specialties
  • American Board of Thoracic Surgery (ABTS) certification info
  • DoD and Air Force equivalent privilege lists for cross-reference

For the most current guidance, consult your local Medical Treatment Facility Credentials Office or the latest AR 40-68 updates via official Army channels.