COLLABORATIVE PRACTICE AGREEMENT DEFINITIONS Collaborative Practice Agreement refers to the formal written statement addressing the parameters of the collaborative practice which are mutually agreed upon by the advanced practice registered nurse and one or more licensed physicians or dentists. Collaborating Professionals refers to _____________________________________________________ (provide Collaborating Physicians name) and _________________________________________________________________________ (provide APRN’s name and licensed APRN specialty i.e.- FNP, ANP, etc.) respectively physician and Advanced Practice Registered Nurse, which have entered into collaborative practices (List all physicians below) _______________________________________________________________ _________________________________________________________________________ Clinical Practice Guidelines refers to written documents, jointly agreed upon by the collaborating professionals that describe a specific plan, arrangement, or sequence of orders, steps, or procedures to be followed or carried out in providing patient care in various clinical situations. These may include textbooks, electronic communications, Internet references, and resources. Responsibilities of the APRN are to see patients in a timely manner, follow practice guidelines and consult collaborating physician as needed. Responsibilities of the collaborating physician are to be available for collaboration at all times either in person or electronically 1. Methods Of Patient Care – The above APRN is authorized to provide professional services within the scope of a __________________________________ (provide APRN licensed specialty in space) within collaborative practice guidelines agreed upon by the collaborative parties. The parameters of this practice include initial or follow-up assessment, history taking, physical examination of patients, and utilization of differential diagnosis, appropriate interventions, consultation and referral as indicated. Emergency treatment and stabilization are also authorized. The parameters of this practice also include (please mark each box that is applicable): 1. Pharmaceutical diagnostic testing - 2. Legend drugs - 3. Controlled substances, see Addendum A, pages 1 & 2 - If APRN is requesting any controlled substances, Addendum A page 1 must be completed and Addendum A page 2 must be signed by APRN and all physicians. 4. Therapeutic regimens - 5. Medical devices and appliances - 6. Receiving and distributing a therapeutic regimen of prepackaged drugs - prepared and labeled by a licensed pharmacist 1
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