Collaborative Practice Agreement

It is the intent of this document to authorize the nurse practitioner at the __________________________ clinic(s) to practice under these protocols without direct supervision. This document sets forth guidelines for collaboration between the physician and the nurse practitioner. Development, Revision and Review The protocols are developed collaboratively by the nurse practitioners and physicians. These protocols will be reviewed by the signatories annually and revised as necessary. Approval The protocols will be approved annually on the initial approval date by the nurse practitioners and collaborating physicians. The Statement of Approval will be signed by all the above parties recognizing the collegial relationship between the parties and their intention to follow these protocols. Signature on the Statement of Approval implies approval of all the policies, protocols and procedures in this document. Nurse practitioners and physicians who join the staff mid-year, or who cover the practice also signify approval of the protocols. Signatories shall be responsible for annual renewal procedures. Setting The nurse practitioners will operate under these protocols at the clinics listed below: Clinic 1 : _____________________________________________________ ____________________________________________________________ ____________________________________________________________ Clinic 2: _____________________________________________________ ____________________________________________________________ ____________________________________________________________ Collaboration The nurse practitioner shall begin formal collaboration on signing with the signatory physician. The nurse practitioner may practice under the protocols established in this document without the direct (on-site) interaction of the collaborating physicians. Consultation with the supervising physicians or his or her designated back-up, will be available at all times, either on-site or by telephone or electronic communication when consultation is needed for any reason. Consultation The nurse practitioner will be responsible for providing health services to clients of the named clinic or agency. The nurse practitioner will provide health promotion, screening, safety instructions, management of acute episodic illness and stable chronic diseases. Referrals will be made, as needed, to other health care providers or specialists. Competencies may include: Elicit and record physical and mental health status, psychosocial history, including review of bodily systems Perform physical examination Initiate appropriate diagnostic tests to screen or evaluate the care-recipient's current health status Assess findings of history, review of systems, physical examination and diagnostic tests, and formulate a diagnosis prior to implementing a treatment regimen Identify health problems and learning needs of the care recipient Plan, teach, promote and manage physical and mental health-care in a continuous patientcentered and holistic program Implement and manage treatment regiments and administer, prescribe, dispense and

procure pharmacological agents Arrange appropriate referrals Initiate appropriate emergency treatment in life-threatening or unusual situations in order to stabilize the care-recipient; and Provide other functions common to the NP for which the ARNP is educationally and experientially prepared. Physician consultation will be sought for all of the following situations and any others deemed appropriate. Whenever a physician is consulted, a notation to that effect, including the physician's name, must be recorded in the patient's medical record. Consultation will occur: Whenever situations arise that go beyond the intent of the protocols or the competence, scope of practice, or experience of the nurse practitioner. Whenever the patient's condition fails to respond to the management plan within an appropriate time frame, based on the provider's clinical judgment. For any uncommon, unfamiliar, or unstable patient condition. For any patient condition which does not fit the commonly accepted diagnostic pattern for a disease/condition. For any unexplained physical examination or historical finding or abnormal diagnostic finding. Whenever a patient requests. For all emergency situations after initial stabilizing care has been initiated. Medical Records The nurse practitioners are responsible for the complete, legible documentation of all patient encounters using the SOAP format, or by other mutually agreed upon method, provided to the clinic within 96 hours of patient encounter. Education, Training, Insurance The nurse practitioners will possess a valid Kansas license as a Registered Nurse and be recognized by the Kansas State Board of Nursing (KSBN) as a Nurse Practitioner. The Nurse Practitioner will be provided appropriate malpractice insurance for a minimum aggregate of $1 million and documentation of same will be provided. Evaluation of Clinical Care Evaluation of the nurse practitioner clinical actions will be provided in the following ways: Review of charts for patients seen by the nurse practitioner, reflecting a minimum of 10% of patient charts and review of care provided. Annual evaluation by the collaborating physician based on previously noted criteria. Informal evaluation during consultations and case review. Periodic chart review as needed. Practice Guidelines The nurse practitioners are authorized to diagnose and treat medical conditions under the following current guidelines (including, but not limited to): Domino, F. (2013). The 5-Minute Clinical Consult, 21ts Ed. New York, NY,: Lippincott Williams & Wilkins or comparable current edition of medical references available on-site at the respective clinic(s). OR

Other published, accepted sources of medical information, as identified below but not limited to: CDC guidelines for immunizations UpTodate Epocrates Johns Hopkins ABX Guide Medscape

Drug Prescriptions Nurse practitioner shall be authorized to prescribe legend drugs as authorized by the KSBN. Authority shall be delegated by collaborating physicians as indicated in the Rules. It is the responsibility of the nurse practitioners to obtain prescription ID numbers from the appropriate Board. References for prescriptions will be the same as the aforementioned practice guidelines.

Collaborating Parties: Statement of Approval We, the undersigned, agree to the terms of this Collaborative Practice Agreement as set forth in this document. _____________________________ Collaborating Physician _____________________________ Collaborating Physician _____________________________ Nurse Practitioner _____________________________ Nurse Practitioner Approval Date (and initials)______________________________________________ Renewal Date (and initials)______________________________________________ Cancellation Date (and initials)___________________________________________