DA Form 5441-55: Orthopaedics Clinical Privileges Guide

DA Form 5441-55: Orthopaedics Clinical Privileges Guide – DA Form 5441-55: Evaluation of Clinical Privileges – Orthopaedics is a key U.S. Army document used to assess and grant clinical privileges to orthopaedic providers in military medical treatment facilities (MTFs).

This form ensures that orthopaedic surgeons and related providers demonstrate the necessary competence for procedures involving the musculoskeletal system, aligning with Army standards for high-quality patient care.

What Is DA Form 5441-55?

DA Form 5441-55, titled Evaluation of Clinical Privileges – Orthopaedics, is a standardized evaluation tool released by the Department of the Army on February 1, 2004. It falls under Army Regulation (AR) 40-68, Clinical Quality Management, with the Office of The Surgeon General (OTSG) as the proponent.

The form evaluates a provider’s demonstrated patient management abilities and technical skills in orthopaedics. It supports credentialing and privileging processes for physicians seeking to perform orthopaedic procedures in Army facilities.

Key Purpose:

  • Document competence in specific orthopaedic procedures.
  • Support initial granting, renewal, or modification of clinical privileges.
  • Ensure patient safety and compliance with military medical standards.

Download the Official Form:
DA Form 5441-55 PDF (from Army Publishing Directorate).

Who Uses DA Form 5441-55?

  • Orthopaedic surgeons and providers in Army Medical Department (AMEDD) facilities.
  • Department/Service Chiefs conducting evaluations.
  • Credentials committees and medical staff for privileging decisions.
  • Military healthcare professionals transitioning or seeking expanded scope of practice.

It applies primarily to active duty, reserve, and civilian providers in U.S. Army healthcare settings. Similar forms exist for other specialties (e.g., DA Form 5441 series).

Structure and Key Sections of the Form

The form is typically 2 pages and includes:

  1. Provider Information (Section at top):
    • Name, Rank/Grade, Period of Evaluation (From/To dates).
    • Department/Service and Facility Name/Address.
  2. Section I – Department/Service Chief Evaluation:
    • Lists specific privileges with a “CODE” column referencing DA Form 5440 (delineation of privileges).
    • Ratings: Acceptable, Unacceptable, or Not Applicable.
    • Providers or evaluators line through non-applicable items.

Common Privileges Evaluated (partial list):

  • Amputation, major.
  • Arthrocentesis, Arthroscopy (diagnostic and surgical), Arthrodesis, Arthroplasty, Arthrotomy.
  • Bone graft procedures, Bone and muscle transposition.
  • Excision of bursae, tumors, herniated nucleus pulposus, etc.
  • Fracture and dislocation management (open/closed reduction, internal/external fixation).
  • Spinal fusions (cervical, thoracic, lumbar), Laminectomy.
  • Osteotomy, Osteomyelitis drainage.
  • Prosthetic joint/bone replacement.
  • Tendon/ligament repairs, Nerve repairs/grafts.
  • Microvascular procedures (e.g., reimplantation of digits).
  • Other: Myelography, regional anesthesia blocks, etc.
  • Section II – Comments:
    • Required explanations for any “Unacceptable” ratings.
    • Evaluator’s name, title, signature, and date.

Approval Codes (cross-referenced to DA Form 5440) typically include levels like full privileges, with supervision, or not approved.

How to Complete DA Form 5441-55?

  • Base evaluations on the provider’s actual experience, training, board certification (e.g., American Board of Orthopaedic Surgery), and recent performance.
  • Enter codes for each privilege category.
  • Mark non-applicable items clearly.
  • Provide detailed comments for any concerns.
  • Forward to the credentials office for review and final approval.

Tips for Accurate Completion:

  • Reference current credentials, case logs, and proctoring records.
  • Align with facility master privileges list and DOD/Army policies.
  • Ensure compliance with licensure and AR 40-68 requirements.

Fillable versions are available on sites like PDFRun or TemplateRoller for convenience, but always use the official PDF for submissions.

Importance in Army Healthcare

Clinical privileging protects patients and maintains standards in military medicine. Orthopaedics covers trauma, sports injuries, degenerative diseases, spine care, and reconstructive surgery—critical for warfighter readiness and beneficiary care.

This form helps standardize evaluations across facilities, supporting seamless transitions for providers and ensuring privileges match demonstrated expertise. It ties into broader credentialing under Title 10 U.S.C. and DOD policies.

  • AR 40-68 Clinical Quality Management — Full regulation governing the process.
  • DA Form 5440-55 — Delineation of Clinical Privileges – Orthopaedics (companion form).
  • Air Force/DOD orthopaedic privilege lists for cross-service reference.
  • Army Publishing Directorate for all DA forms.

For questions on completing or submitting this form, consult your local Medical Treatment Facility Credentials Office or refer to current AMEDD guidance. Policies can evolve, so verify the latest version on official Army sites.