DA Form 5441-19: Dietetics Clinical Privileges Guide

DA Form 5441-19: Dietetics Clinical Privileges Guide – Registered dietitians (RDs) and nutrition professionals in the U.S. Army play a critical role in patient care, performance optimization, and medical readiness. DA Form 5441-19, titled Evaluation of Clinical Privileges – Dietetics, is the official U.S. Army document used to assess and grant clinical privileges to dietetics providers.

This form ensures that dietitians demonstrate competence in key areas like nutritional assessment, medical nutrition therapy (MNT), and ordering privileges, all in compliance with AR 40-68 (Clinical Quality Management).

What Is DA Form 5441-19?

DA Form 5441-19 (February 2004 edition) is a two-page evaluation tool for dietetics clinical privileges. It is used by Department/Service Chiefs to rate providers on Category I and Category II privileges based on demonstrated performance.

  • Purpose: Document competence in patient management, technical skills, and procedures specific to dietetics.
  • Governing Regulation: AR 40-68, which outlines the Army Medical Department’s Clinical Quality Management Program (CQMP).
  • Official Download: Direct PDF from Army Publishing Directorate.

The form pairs with DA Form 5440-19 (Delineation of Clinical Privileges – Dietetics) for initial requests.

Who Uses DA Form 5441-19?

  • Army Registered Dietitians (65C Area of Concentration).
  • Civilian dietitians working in Army medical treatment facilities (MTFs).
  • Providers seeking reappraisal, renewal, or initial privileging.
  • Evaluators: Department/Service Chiefs or designated supervisors.

It applies across Army hospitals, clinics, and field environments where nutritional care supports soldier readiness, wound healing, chronic disease management, and performance nutrition.

Key Sections of DA Form 5441-19

Section I – Department/Service Chief Evaluation

Category I Clinical Privileges (Core privileges, typically independent):

  • Evaluation:
    • Classify clinical nutrition category.
    • Recommend community support programs.
    • Evaluate diet orders.
    • Classify stages of change.
  • Procedures:
    • Anthropometric measurements and body composition.
    • Blood glucose monitoring with glucometer.
  • Orders (Many independent or per protocol):
    • Diet orders, calorie levels, supplements, calorie counts.
    • Specific lab studies (albumin, prealbumin, glucose, HbA1c, lipids, etc.).
    • Vitamin/mineral supplements and referrals.
  • Medical Nutrition Therapy (MNT): General/life-cycle diets, modified consistency, neonatal, pediatric, geriatric, cardiovascular, GI, renal, hepatic, diabetic, psychiatric, test diets, and nutrition support.

Category II Clinical Privileges (Often require physician co-signature or additional oversight):

  • Tube feedings and parenteral formulas (per local policy).
  • Transitional feedings.
  • Teaching blood glucose monitoring.
  • Indirect calorimetry.

Evaluators mark Acceptable, Unacceptable, or Not Applicable. Any “Unacceptable” rating requires detailed explanation in Section II – Comments.

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

  1. Fill provider details (Name, Rank/Grade, Evaluation Period, Facility).
  2. Evaluate each privilege category using direct observation, chart reviews, and performance data.
  3. Enter privilege approval codes from the corresponding DA Form 5440.
  4. Provide comments for any deficiencies.
  5. Evaluator signs and dates.
  6. Use results for recredentialing, privileging decisions, and quality improvement per AR 40-68.

Pro Tip: Line through and initial any non-applicable items. Keep documentation current for Joint Commission and other accreditation standards.

Why Clinical Privileges Matter for Army Dietitians?

Privileging ensures safe, evidence-based care aligned with the 2024 Scope and Standards of Practice for Registered Dietitian Nutritionists (RDNs). In the military, this supports:

  • Optimizing soldier performance and recovery.
  • Managing chronic conditions (diabetes, renal disease, etc.).
  • Nutrition support in critical care and field operations.

Accurate privileging protects patients, providers, and the institution while enabling advanced practice (e.g., independent ordering where authorized).

  • AR 40-68: Full Clinical Quality Management regulation.
  • Army Dietitian Career Information: goarmy.com (65C).
  • DoD and Air Force equivalents for cross-service reference.
  • Academy of Nutrition and Dietetics Scope of Practice for guidance on competencies.

Download the Form Here: DA Form 5441-19 PDF

Need Help?

For questions on completing DA Form 5441-19, contact your local Medical Treatment Facility’s Credentials Office or Clinical Quality Management team. Always refer to the most current version on armypubs.army.mil.