DA Form 5441-10: Psychiatry Clinical Privileges Guide

DA Form 5441-10: Psychiatry Clinical Privileges Guide – U.S. Army psychiatrists, behavioral health professionals, and medical staff working in military treatment facilities (MTFs) rely on DA Form 5441-10 as a key document for evaluating and renewing clinical privileges in psychiatry. This form ensures providers meet rigorous standards for patient care, safety, and competency under Army regulations.

What Is DA Form 5441-10?

DA Form 5441-10, titled Evaluation of Clinical Privileges – Psychiatry, is an official U.S. Army form (February 2004 edition) used to assess a provider’s demonstrated abilities in psychiatric patient management and specific technical procedures.

The Department of the Army (DA) prescribes it for use with AR 40-68, Clinical Quality Management (with rapid action revisions). The proponent agency is the Office of The Surgeon General (OTSG).

Primary Purpose:

  • Evaluate competence across core and subspecialty psychiatric privileges.
  • Support initial granting, renewal, or modification of clinical privileges.
  • Document performance for reappraisal and medical staff appointment/reappointment.

Download the Official Form:
DA Form 5441-10 PDF (Direct from Army Publishing Directorate).

Who Uses DA Form 5441-10?

  • Psychiatrists (MD/DO) in Army MTFs.
  • Department/Service Chiefs or designated evaluators.
  • Credentials Committees at military hospitals and clinics.
  • Providers seeking or renewing privileges in adult, child/adolescent, forensic, geriatric, addiction, or consultation-liaison psychiatry.

It forms part of the broader Army credentialing and privileging process managed through systems like the Joint Centralized Credentials Quality Assurance System (JCCQAS).

Key Sections of DA Form 5441-10

The two-page form includes structured evaluation criteria:

Header Information:

  • Provider name, rank/grade, evaluation period.
  • Department/Service and facility details.

Section I – Department/Service Chief Evaluation:

  • Privilege Categories (I through IV) with approval codes linked to DA Form 5440.
  • Subspecialties: Child Psychiatry, Psychoanalysis, Child Psychoanalysis, Forensic Psychiatry, Administrative Psychiatry, Geriatric Psychiatry, Consultant-Liaison Psychiatry, Addictions Medicine, Psychopharmacology.
  • Core Privileges Requested (rated as Acceptable, Unacceptable, or Not Applicable):
    • Assessment and Diagnosis of Mental Disorders.
    • Inpatient Psychiatric Treatment.
    • Alcohol/Substance Abuse Treatment (including Residential).
    • Adult Psychotherapy (Individual, Marital, Family, Group).
    • Child and Adolescent Psychiatry (Assessment, Psychotherapy, Psychopharmacotherapy).
    • Somatic Therapy (Psychopharmacotherapy, Biofeedback, Electro-Convulsive Therapy, Amytal Interview).
    • Consultation (Command-directed evaluations, Psychological Autopsies, Medical/Surgical, Community, School).
    • Specialized Skills (Forensic, Psychoanalysis, Behavior Therapy, Gestalt, Hypnotherapy, Dangerousness Evaluations).
    • Research and Other (Specify).

Section II – Comments:
Any “Unacceptable” ratings require detailed explanation. These comments directly influence re-privileging decisions.

The evaluator signs with name, title, and date.

How to Complete and Use the Form? (Step-by-Step)

  1. Fill Provider & Facility Details — Enter accurate information.
  2. Review All Applicable Privileges — Line through and initial non-applicable items.
  3. Assign Codes — Reference the corresponding DA Form 5440 for privilege levels.
  4. Rate Performance — Base ratings on observed competence, patient outcomes, and documentation.
  5. Document Unacceptable Ratings — Provide specific explanations in Section II.
  6. Submit for Review — Route through the credentials process per AR 40-68 and MTF policy.

Tip: Use fillable PDF tools for digital completion where authorized, but always verify with official Army systems.

Importance in Army Clinical Quality Management

AR 40-68 governs the Army’s Clinical Quality Management Program (CQMP), emphasizing credentialing, privileging, performance improvement, and risk management. DA Form 5441-10 helps maintain high standards in behavioral health, ensuring providers deliver safe, evidence-based care to service members, families, and other beneficiaries.

Regular evaluations (typically every 2 years or as required) support continuous professional development and compliance with DoD and Joint Commission standards.

  • DA Form 5440 Series — Delineation of Clinical Privileges.
  • Other DA 5441 variants for related fields (e.g., Clinical Psychology – DA 5441-11, Psychiatric Advanced Practice Nurse).
  • AR 40-68 (full regulation via Army Publishing Directorate).
  • JCCQAS for electronic credentialing.

Need Help with DA Form 5441-10?

Military healthcare professionals should consult their MTF Credentials Manager, Department Chief, or the Army Medical Department Office of Quality Management for guidance. Always use the most current official forms and regulations.

Official Download: https://armypubs.army.mil/pub/eforms/DR_a/pdf/A5441_10.pdf