DA Form 5441-23: Emergency Medicine Clinical Privileges

DA Form 5441-23: Emergency Medicine Clinical Privileges – DA Form 5441-23: Evaluation of Clinical Privileges – Emergency Medicine is a key U.S. Army form used for assessing and granting clinical privileges to healthcare providers in emergency departments within military treatment facilities (MTFs).

This form supports the Army’s Clinical Quality Management Program under AR 40-68, ensuring providers demonstrate competence in managing a wide range of emergency conditions and performing critical procedures.

What Is DA Form 5441-23?

DA Form 5441-23 (dated FEB 2004) is titled Evaluation of Clinical Privileges – Emergency Medicine. Department/service chiefs or evaluators use it to rate providers on patient management abilities and technical skills specific to emergency medicine.

It aligns with the corresponding DA Form 5440 series for initial privilege delineation. The form covers core emergency care categories and procedures, with ratings of Acceptable, Unacceptable, or Not Applicable. Any “Unacceptable” ratings require detailed explanations in Section II – Comments.

Official Download Link:
DA Form 5441-23 PDF (U.S. Army Publications)

This form applies primarily to Army physicians, physician assistants, and other privileged providers working in Emergency Medicine at military hospitals and clinics. Evaluations feed into reappraisal, renewal of privileges, and medical staff appointments.

Purpose and Regulatory Background

The form implements AR 40-68 Clinical Quality Management (with updates through 2009 RAR), which governs credentialing, privileging, and quality assurance across the Army Medical Department (AMEDD).

Key goals include:

  • Verifying provider competence for high-acuity emergency care.
  • Supporting patient safety and risk management.
  • Ensuring alignment with standards like those from the American College of Emergency Physicians (ACEP) for delineation of privileges.

Privileging in the Military Health System (MHS) is portable across facilities, reflecting demonstrated competence, training, licensure, and ongoing performance.

Key Sections of DA Form 5441-23

Section I – Department/Service Chief Evaluation evaluates two main areas:

1. Privilege Categories (Patient Management)

Evaluators rate the provider on conditions such as:

  • Altered levels of consciousness
  • Eye trauma or illness
  • Acute respiratory illnesses and failure
  • Acute cardiac emergencies (MI, arrhythmias, heart failure)
  • Acute abdominal disorders, GI illness
  • Poisoning, caustic ingestions, electrical/chemical injuries
  • OB/GYN problems, rape/sexual assault victims
  • Psychiatric illness, substance withdrawal
  • Trauma management: musculoskeletal, head/neck, multiple trauma, burns, gunshot/knife wounds
  • Mass casualty and triage supervision
  • Pre-hospital/EMT care oversight

2. Procedures/Skills

Critical technical competencies include:

  • Diagnostic testing, X-ray/EKG interpretation
  • Vascular access (peripheral IV, central lines, arterial)
  • Airway management (intubation, cricothyrotomy)
  • Thoracostomy, ventilator management
  • Cardioversion, pacemaker placement, pericardiocentesis
  • Lumbar puncture, paracentesis, thoracentesis
  • Fracture/dislocation reduction
  • Ultrasound (FAST, procedural, limited echo/biliary/aortic)
  • Sedation/analgesia, rapid sequence induction (RSI)

Evaluators enter privilege approval codes from the related DA Form 5440 and mark non-applicable items.

Section II – Comments: Mandatory explanations for any unacceptable ratings. The evaluator signs and dates the form.

Who Uses This Form?

  • Army Emergency Medicine Physicians (board-certified or eligible via ABEM/AOBEM pathways).
  • Providers in Army MTF Emergency Departments.
  • Evaluators: Department Chiefs or designated supervisors.
  • It supports initial granting, renewal (typically periodic), and focused professional practice evaluation (FPPE/OPPE) processes common in MHS credentialing.

Similar forms exist for other specialties (e.g., DA 5441 series), but 5441-23 is specific to Emergency Medicine.

How to Complete and Use DA Form 5441-23?

  1. Fill provider details (Name, Rank, Evaluation Period, Facility).
  2. Rate each category/procedure based on direct observation, chart review, or proctoring.
  3. Use privilege codes from DA Form 5440.
  4. Provide comments for deficiencies.
  5. Incorporate into credentialing committee reviews per AR 40-68.

Providers must maintain current licensure, BLS/ACLS/PALS/ATLS certifications, and demonstrate ongoing competence.

Importance for Military Emergency Medicine Careers

Accurate completion of this form ensures qualified providers deliver life-saving care in garrison and deployed settings. Emergency Medicine in the Army involves treating Soldiers, families, and civilians, often in austere environments. Proper privileging supports readiness and aligns with civilian standards while meeting DoD/MHS requirements.

For civilians or contractors in Army facilities, similar privileging processes apply, emphasizing unrestricted licenses and specialty-specific experience.

  • AR 40-68: Full Clinical Quality Management regulation.
  • ACEP Guidelines on Credentialing and Privileging in Emergency Medicine.
  • Army Publishing Directorate for all DA Forms.
  • MHS System-Wide Privileging information.

Note: Always use the most current official versions from armypubs.army.mil. Policies may evolve; consult your local Medical Staff Office or credentials committee for facility-specific guidance.