It is the intent of this document to authorize the nurse practitioner(s) at the __________________________ clinic(s) to practice under these protocols without direct supervision, as specified in the Medical Practice Act, Texas Civil Statutes, Article 4495b, section 3.06(d)(5) and (6). This document sets forth guidelines for collaboration between the supervising physician(s) and the nurse practitioner(s).
Development, Revision and Review
The protocols are developed collaboratively by the nurse practitioners, delegating medical director, and supervising physicians. These protocols will be reviewed annually and revised as necessary.
Approval
The protocols will be approved annually on the initial approval date by the nurse practitioners, medical director, and supervising 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. It is the task of the medical director to see that the written approval of all the above parties is obtained.
Setting
The nurse practitioners will operate under these protocols at the (Name of Institution) clinics listed below:
Clinic 1 : (name and address)
Clinic 2 : (name and address)
Supervision
The nurse practitioners are authorized to practice under the protocols established in this document with out the direct (on-site) supervision or approval of the supervising physicians. Consultation with the supervising physicians or their designated back-up, is available at all times, either on-site or by telephone when consultation is needed for any reason.
Consultation
The nurse practitioners are responsible for providing health services to clients of the (name of clinic or agency). The nurse practitioners 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.
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:
Medical Records
The nurse practitioners are responsible for the complete, legible documentation of all patient encounters using the SOAP format.
Education and Training
The nurse practitioners must possess a valid Texas license as a Registered Nurse and be recognized by the Texas Board of Nurse Examiners as a Nurse Practitioner.
Evaluation of Clinical Care
Evaluation of the nurse practitioners will be provided in the following ways:
A minimum of a monthly review by the supervising physicians of a minimum of 10% of patient charts. A written record of the review is to be kept.
Annual evaluation by the supervising physicians based on written criteria.
Informal evaluation during consultations and case review.
Periodic chart review a part of chart audits by the Quality Assurance Committee.
Practice Guidelines
The nurse practitioners are authorized to diagnose and treat common medical conditions under the following current guidelines (including, but not limited to):
Barker, LR, Burton, JR & Zieve, PD. (1999). Principles of Ambulatory Medicine 5th Ed., Williams & Wilkins or comparable current edition of medical references available on-site at the respective clinics.
OR
Other published, accepted sources of medical information, as agreed upon by the collaborating parties and/or identified below:
Drug Prescriptions
Nurse practitioners at this facility shall be authorized to prescribe dangerous drugs (excluding, controlled substances) as authorized by the Texas Board of Nurse Examiners (BNE) under Rule 222, Advanced Practice Nurses Limited Prescriptive Authority and the Texas Board of Medical Examiners (BME) under Rules 193.2-193.4 and 193.8, Delegation of Prescriptive Authority. Authority shall be delegated by the Medical Director of the Methodist Health Care Ministries and supervision of prescribing activity shall be conducted by the Medical Director and supervising physicians as indicated in the Rules. It is the responsibility of the nurse practitioners to obtain prescription ID numbers from the appropriate Board. The Medical Director shall inform the BME, in writing, of his intent to delegate prescriptive authority as required in the Rules.
References for prescriptions will be the current Physician's Desk Reference and/or the Nurse Practitioner/Physician Monthly or Quarterly Prescribing Guide. Additionally, there may be limitations placed on prescriptions to an approved formulary for the MHCM.
Collaborating Parties: Statement of Approval
We, the undersigned, agree to the terms of this Collaborative Practice Agreement as set forth in this document.
_____________________________ Medical Director
_____________________________ Supervising Physician
_____________________________ Supervising Physician
_____________________________ Supervising Physician
_____________________________ Nurse Practitioner
_____________________________ Nurse Practitioner
_____________________________ Nurse Practitioner
Approval Date ______________
Renewal Date ______________
Renewal Date ______________
NOTE: This is an example of a broad collaborative practice agreement. Permission is given to download, copy or modify. Each state will have different board of nursing or public health code rules and regulations that will need to be identified in the wording.
Copyright: Judith C.D. Longworth, 1998, 2001