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Kelly Johnson

Practice Agreement / Practice Protocol for Physicians and Nurse Practitioners in


Collaborative Practice at XYZ Medical Center

Purpose
This document authorizes the acute care nurse practitioner (ACNP) to perform medical acts in
accordance with the Mississippi Nursing Practice Law, §73-15-20. This document delegates
certain medical acts, as required by Mississippi law, and sets forth guidelines for collaboration
between the delegating physician, Dr. ______________, a Mississippi licensed physician whose
practice or prescriptive authority is not limited as a result of voluntary surrender or
legal/regulatory order. and Kelly Johnson, MSN, RN, ACNP.

This agreement is not intended to limit the health care services the ACNP provides under their
scopes of practice, based on the advanced practice role and specialty authorized by the
Mississippi Board of Nurse Examiners.

Scope of Practice
The role of the ACNP is to provide advanced nursing care across the continuum of health care
services to meet the specialized physiologic and psychologic needs of patients with complex
acute, critical, and chronic health conditions. This care is continuous and comprehensive. The
population in acute care practice includes acutely, and critically ill patients experiencing episodic
illness, exacerbation of chronic illness, or terminal illness.

The ACNP practices with a focus on the adult population, those age 15 and older and not
pregnant, in any setting in which privileges exist (inpatient and outpatient), and in which patient
care requirements include management/stabilization of chronic and acute illness, complex
monitoring and therapies, high-intensity nursing intervention, or continuous nursing vigilance
within the range of high-acuity care.

Diagnoses seen by the ACNP include, but are not limited to: hypertension, hyperlipidemia,
coronary artery disease, congestive heart failure, atrial fibrillation, ventricular
arhthmias/dysrythmias, diabetes mellitus, chronic obstructive pulmonary disease, pneumonia,
influenza, acute respiratory distress syndrome, sepsis, abscess, sinusitis, rhinitis, phyrangitis,
pancreatitis, gastroesphogeal reflux disease, and lumbago.

In addition to functions/procedures within the scope of RN practice, services in the ACNP’s scope
of practice include, but are not limited to:

Health Promotion, Health Protection, Disease Prevention, and Treatment


• Performing physical examinations and medical histories
• Diagnosis and management of acute episodic illness and chronic conditions that
may result in rapid physiologic deterioration or life-threatening instability
• Reformulating diagnoses by priority based on new or additional assessment data
and the dynamic nature of complex acute, critical, and chronic illness.
• Synthesis of data from a variety of sources to make clinical judgments and
decisions about appropriate recommendations and treatments.
• Prioritization of health problems during complex acute, critical, and chronic
illness
Kelly Johnson

• Formulation of differential diagnoses by priority considering multiple potential


mechanisms causing complex acute, critical, and chronic illness states.
• Institute emergency measures and emergency treatment or appropriate stabilization
measures in situations such as cardiac arrest, shock, hemorrhage, convulsions,
poisoning, and allergic reactions
• Arrange inpatient admissions and discharges; perform rounds and record appropriate
patient progress notes; compile detailed narrative and case summaries; complete
forms pertinent to patients' medical records
• Ordering/interpreting laboratory tests (CBC, CMP, HbA1C, lipid profile, thyroid
function, hepatic function, coagulation factors)
• Ordering/interpreting diagnostic/radiologic tests (radiographs, CT, MRI, stress
test, DEXA, EKG, echocardiogram)
• Providing health promotion and safety instructions
• Performing bedside procedures (I&D, suturing, arterial line and central venous
line insertion)
• Referral to other health care providers, as needed.

Nurse Practitioner-Patient Relationship


• Creating a climate of mutual trust and establishes partnerships with patients.

Teaching-Coaching Function
• Eliciting from the patient the characteristics of his/her learning style from which
to plan and implement the teaching.
• Communicating health advice, instruction and counseling appropriately using
evidence-based rationale.

Professional Role
• Functioning in a variety of role dimensions: health care provider, coordinator,
consultant, educator, coach, advocate, administrator, researcher, and leader.
• Advocating for the patient to ensure health needs are met.
• Advocating for access to quality, cost-effective health care.

Managing and Negotiating Health Care Delivery Systems


• Considering access, cost, efficacy, and quality when making care decisions
• Participating as a key member of an interdisciplinary team through the
development of collaborative and innovative practices.
• Advocating for increasing access to health care for all.

Monitoring and Ensuring the Quality of Health Care Practice


• Monitoring quality of own practice and participating in continuous quality
improvement based on professional practice standards, relevant research, statutes,
and regulation.

Cultural/Spiritual Competence
• Showing respect for the inherent dignity of every human being, whatever their
age, gender, religion, socioeconomic class, sexual orientation, and ethnicity.
• Recognizing cultural issues and interacting with patients from other cultures in
culturally sensitive ways.
Kelly Johnson

• Assessing influence of spirituality on one’s health care behaviors and incorporate


these beliefs into the plan of care to meet spiritual needs of the patient

Restorative care is the focus of the ACNP, and short-term goals include patient stabilization,
minimization of complications, and promotion of physical and psychological well-being. The
long-term goal is to restore maximal health potential while evaluating risk factors in achieving
this outcome.

Prescriptive Authority & Other Medical Acts


The nurse practitioner may establish medical diagnoses for patients that are within her scope of
practice, and order/prescribe drugs and medical devices as authorized in accordance with the
Mississippi Board of Nursing and in accordance to standards and guidelines of the national
certification organization. The medical aspects of care provided by the ACNP under this protocol
shall be in connection with providing primary care and preventative services to patients served
by XYZ Medical Center. These services are provided within the framework of acute and primary
health care and in collaboration of a physician. Services provided include, but are not limited to,
management of acute illnesses and injuries; chronic disease management for stable conditions,
assisting with and performing procedures, and consultation/referral. A patient’s medical care
shall be reviewed with a physician in a timely manner.

The nurse practitioner shall practice according to standards and guidelines of the American
Nurses Credentialing Center (ANCC) and in a collaborative/consultative relationship with a
licensed physician whose practice is compatible with that of the nurse practitioner. The nurse
practitioner must be able to communicate reliably with a collaborating/consulting physician at all
times while practicing.

Some medications that will be routinely prescribed include, but are not limited to:
antihypertensives (lisinopril, carvedilol, amlodipine), antilipids (atorvastatin, fenofibrate),
antiarrhythmics (diltiazem, amiodarone), antibiotics (levofloxacin, clarithromycin), proton pump
inhibitors (esomeprazole, pantoprazole), narcotics (morphine, oxycodone), vasopressors
(neosyneprine, norepinephrine ), diuretics (furosemide, hydrochlorothiazide), antidiabetics
(regular insulin, metformin), inotropics (dobutamine, digoxin), and bronchodilators (albuterol).

Nurse practitioners may not write prescriptions for, dispense or order the use of or administration
of any schedule of controlled substances except as follows:

• Pursuant to a physician's order, the nurse practitioner may call-in a prescription for any
schedule of controlled substances or administer any schedule of controlled substances,
but only after the physician has made an independent determination as to the need for
the controlled substance and this is documented in the patient records.
• Pursuant to these regulations of the State of Mississippi, and once registered with the
U.S. Drug Enforcement Administration in compliance with Title 21 CFR Part 1301 Food
and Drugs; the authorized nurse practitioner may prescribe Schedules II-V.
• The ACNP registered to prescribe controlled substances may order, possess, prescribe,
administer, distribute or conduct research with those substances to the extent authorized
by their registration and in conformity with the other provisions of these regulations and
in conformity with provisions of the Mississippi Uniform Controlled Substances Law,
Miss. Code Ann. §41-29-101 et seq.
Kelly Johnson

Collaboration/Consultation
Each collaborative/consultative relationship shall include and implement a formal quality
assurance/quality improvement program which shall be maintained on site and shall be
available for inspection by representatives of the Mississippi Board of Nursing and
Mississippi State Board of Medical Licensure. The quality assurance/quality
improvement program criteria shall consist of:

• Review by collaborative physician of a sample of charts that represent 10% or 20


charts, whichever is less, of patients seen by the advanced practice registered nurse
every month. Charts should represent the variety of patient types seen by the
advanced practice registered nurse. Patients that the advanced practice registered
nurse and collaborating physician have consulted on during the month will count as
one chart review.
• The ACNP shall maintain a log of charts reviewed which includes the identifier for the
patients’ charts, reviewers’ names, and dates of review. Each advanced practice
registered nurse shall meet face to face with a collaborating
physician once per quarter for the purpose of quality assurance.
• The ACNP who prescribes a controlled substance shall maintain a complete record of her
examination, evaluation and treatment of the patient which must include documentation
of the diagnosis and reason for prescribing controlled substances; the name, dose,
strength, quantity of the controlled substance and the date that the controlled substance
was prescribed. The record required by this subsection shall be maintained in the patient's
medical records, provided that such medical records are maintained at the practice site of
the nurse practitioner and are available for inspection by the representatives of the
Mississippi Board of Nursing pursuant to authority granted in Miss. Code Ann. §41-29-
125 (S upp. 1986).
• The Patient Record required by these regulations shall be maintained in the office of the
nurse practitioner for a period of seven (7) years from the date that the record is
completed or the controlled substances, legend drugs or other medications are
prescribed and shall be made available for inspection by representatives of the
Mississippi Board of Nursing pursuant to authority granted in Miss. Code Ann. §41-29-
125 (Supp. 1986).

Education/Training
• Current license as a RN in Mississippi
• Registered with the U.S. Drug Enforcement Administration
• Masters of Science in Nursing, ACNP
• Graduate of accredited Nurse Practitioner Program
University of South Alabama, College of Nursing
Mobile, Alabama
Graduation Date: December 2009
• 680 clinical hours have been completed in acute care settings
• Eligibility to practice as an ACNP in the state of Mississippi.
• Certified ACLS & BLS provider 04/2009-04/2011
• Current DEA number from the United States Drug Enforcement Administration

Prior to certification:
Kelly Johnson

• Temporary certification will be obtained to practice for a maximum of 120 days


from the date of completion of a nurse practitioner program. Graduates of nurse
practitioner programs must practice under the direct supervision of a licensed
physician or a certified nurse practitioner while practicing with a temporary
permit or for a minimum of 90 days, whichever is longer.

Prior to practicing as a nurse practitioner, the new graduate will:


• Submit required applications and fees
• Submit official evidence of graduation from a nurse practitioner program of study
and clinical experience which occurred
• Submit evidence of registration to take the national certification examination
within 90 days of completion of a nurse practitioner program
• Submit evidence that certification examination results will be sent directly to the
Board from the national certifying body
• Submit required practice documentation for approval by the Board (approval must
be granted prior to practicing as a nurse practitioner).
• Nurse practitioner applicants applying for controlled substance prescriptive
authority must complete a Board approved educational program prior to making
application.

In event of license renewal:


• The board shall renew a license for an advanced practice registered nurse upon
receipt of the renewal application, fees and protocol or practice guidelines. The
board shall adopt rules establishing procedures for license renewals. The board
shall by rule prescribe continuing education requirements for advanced practice
nurses not to exceed forty (40) hours biennially as a condition for renewal of a
license or certificate.

Changes in status:
• The advanced practice registered nurse shall notify the board immediately
regarding changes in the collaborative/consultative relationship with a licensed
physician or dentist. If changes leave the advanced practice registered nurse
without a board approved collaborative/consultative relationship with a physician
or dentist, the advanced practice nurse may not practice as an advanced practice
registered nurse.

Development, Revision, Review and Approval


This protocol has been developed collaboratively by the nurse practitioner and delegating
physician. Protocols will be reviewed annually, dated, and signed by the above parties and any
alternate physicians. The agreement and/or associated treatment guidelines will be revised more
frequently as necessary. The “Statement of Approval” will be signed by all 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, or referenced in, this document. Nurse practitioners and physicians who join the
staff after approval or renewal also review and sign the protocols.

Setting
The nurse practitioners will practice under these protocols at the following sites.
Kelly Johnson

Name of Hospital & Service Address Type of Practice


or Name of Practice Site
Site # 1 XYZ Medical Center ??????????????????? Outpatient clinic
Site # 2 123 Medical Center ??????????????????? Inpatient hospital
Site # 3 ABC Medical Center ??????????????????? Inpatient hospital

Collaborating Parties: Statement of Approval

We, the undersigned, agree to the terms of this Collaborative Practice Agreement as set forth in
this document.
_____________________________ Delegating Physician

_____________________________ Nurse Practitioner

_____________________________ Alternate Physician

_____________________________ Alternate Physician

_____________________________ Alternate Physician


Kelly Johnson

_____________________________ Alternate Physician

_____________________________ Alternate Physician

_____________________________ Alternate Physician

_____________________________ Alternate Physician

Approval Date ________________

Reviewed on __________________

Reviewed on __________________

Reviewed on __________________

Reviewed on __________________

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