PIEDMONT ACCESS TO HEALTH SERVICES, INC. Policy Number: 01-02-015 SUBJECT: Practice Agreement for Patient Care Conducted by a Licensed Nurse Practitioner EFFECTIVE DATE: 09/25/2006 REVIEWED/REVISED: 07/02/2007, 03/04/2009, 03/30/2010, 06/11/2010, 01/23/2012, 07/17/2012 POLICY: PATHS is dedicated to providing the highest quality of care to its patients. A licensed, registered nurse who holds a graduate degree in nursing from an accredited nurse practitioner education program, who has successfully passed a professional certification examination recognized by the Virginia Board of Nursing and the Virginia Board of Medicine, and who has been duly licensed by the Commonwealth of Virginia as a Licensed Nurse Practitioner, is eligible for employment as a provider of patient care by PATHS Community Medical Center. AUTHORITY: This document is in accordance with the requirements of the statutory authority 54.1-2400 and 54.1-2957 of the Code of Virginia dated December 25, 2008, entitled Regulations Governing the Licensure of Nurse Practitioners and 54.1-2957.01 of the Code of Virginia, dated December 24, 2008, entitled Regulations for Prescriptive Authority for Nurse Practitioners. PROCEDURE: The practice of a licensed nurse practitioner shall be based on specialty education preparation as a nurse practitioner and in accordance with standards of the applicable certifying organization and written protocols as defined in 18 VAC 90-30-10 et seq. 1. A licensed nurse practitioner shall be authorized to engage in practices constituting the practice of medicine in collaboration with, and under the medical direction and supervision of a licensed physician(s). 2. Medical direction and supervision means participation in the development of a written protocol including provision for periodic review and revision, development of guidelines for availability and ongoing communications which provide consultation among collaborating parties and the patient, and periodic joint evaluation of services provided, e.g., chart review and review of patient outcomes. 3. Protocol means a written statement, jointly developed by the collaborating physician(s) and the licensed nurse practitioner(s), that directs and describes the procedures to be followed and the delegated medical acts appropriate to the specialty practice area to be performed by the licensed nurse practitioner(s) in the care and management of patients. The written protocol shall include the Page 1 of 8
nurse practitioner s authority for signatures, certifications, stamps, verifications, affidavits, and endorsements, provided it is: a. In accordance with the specialty license of the nurse practitioner and with the scope of practice of the supervising physician(s). b. Permitted by 54.1-2957.02 or applicable sections of the Code of Virginia; and c. Not in conflict with federal law or regulation. 4. A nurse practitioner shall perform duties as outlined in PATHS Practice Agreement for Patient Care Conducted by a Licensed Practitioner. PATHS has selected and will ensure to provide the following materials at each patient care site for easy access to general guidance regarding the provision of care: a. 5-minute Clinical Consult 2010 (10 th Ed.) ; and b. Current Medical Diagnosis and Treatment 2009. When a question arises as to the appropriateness of any treatment or therapy outlined in these materials, the Nurse Practitioner is required to consult his/her supervising physician. Any such consult should be clearly documented in the patient record. 5. The physician assigned to the center where the nurse practitioner is assigned will serve as the supervising physician. All other physicians employed by PATHS shall be designated alternate supervising physicians. Physician supervision will be available at all times, either on-site or by telephone, when consultation is needed for any reason. In accordance with 18VAC90-40-100, should the nurse practitioner practice at a site different than that of the supervising physician, the supervising physician shall provide supervisory services to such separate practices by making regular site visits for consultation and direction for appropriate patient management. The site visits shall occur no less frequently than once a quarter. 6. A nurse practitioner will be managing primary care conditions and developing treatment plans utilizing the resources listed in Appendix 1 of this document. In general, however, physician consultation will be sought for all 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 made in the patient chart. Additionally, the physician consulted with will co-sign the progress note after it has been completed by the nurse practitioner. a. Whenever situations arise which go beyond the intent of the protocols or the competence, scope of practice experience of the nurse practitioner; b. Any uncommon, unfamiliar or unstable patient conditions; Page 2 of 8
c. Any patient conditions which do not fit the commonly accepted diagnostic patterns for a disease or disorder; d. Any patient conditions failing to respond to the treatment plan in an appropriate time frame; e. Any unexplained physical examination or historical finding; f. Whenever a patient, nurse practitioner or physician requests; and/or g. All emergency situations after initial stabilizing care has been initiated. 7. Responsibilities of the Supervisor: The supervisor shall: a. Be responsible for all invasive procedures. b. Be responsible for all prescriptions issued by the nurse practitioner and attest to the competence of the nurse practitioner to prescribe drugs and devices. The physician maintains ultimate responsibility for the agreed-upon course of treatment and medications prescribed. c. Participate in informal evaluation during consultations and case review, and conduct a monthly, random review of no less than five (5) patient charts on which the nurse practitioner has entered a prescription for an approved drug or device. d. Supervise and direct, at any one time, no more than four nurse practitioners with prescriptive authority. e. Regularly practice in any location in which the licensed nurse practitioner exercises prescriptive authority, except as noted in Section B, subset 5. 8. Responsibilities of the Nurse Practitioner: A licensed nurse practitioner, under the supervision of a physician licensed in the Commonwealth of Virginia, is expected to perform the following duties marked with an x below: a. Obtain comprehensive health, medical and developmental histories; b. Perform physical exams based on age and history; c. Order and interpret age-appropriate screening tests, lab tests and diagnostic procedures; d. Assess and diagnose both chronic and acute illnesses common in a family practice outpatient setting; e. Formulate a holistic, family centered plan of care; Page 3 of 8
f. Consult with supervising physicians; g. Make referrals to other health care providers in the community as necessary; h. Provide comprehensive health plans including advising patients about health issues provide management plans and anticipatory guidance; i. Treat chronic and acute illnesses within scope of a general family practice; j. Prescribe or order appropriate pharmacological and nonpharmacological interventions; k. Provide follow-up and care that reflects evidence-based practice; l. Monitor and evaluate accuracy of diagnosis and effectiveness of prescribed treatment plans; m. Monitor patient response to treatment; n. Participate in continuous quality improvement processes; o. Perform simple office procedures that may include: i. Abscess I&D (non-facial) less than 5cm; ii. iii. iv. Punch or shave biopsy; Suture laceration (non-facial) less than 10cm; Mole/Wart removal (non-facial) via excisional bx less than 3cm; v. Epidermal cyst removal (non-facial) less than 3cm; vi. vii. viii. ix. Wound debridement; Suturing/continuous staples; Injections; Removal of foreign bodies from the skin; x. Care of superficial wounds; xi. xii. Removal of sutures/staples; Disimpaction; Page 4 of 8
xiii. xiv. Pelvic examinations to include collection of STD cultures, wet mount slides, and PAP smears; and/or Simple urinary catheterization. p. A nurse practitioner will be expected to treat 16 18 patients per day. Walk-ins and unscheduled patients who present for treatment may be worked into the schedule depending on the nature of the illness or presenting complaint. q. A nurse practitioner will perform well-child and adult examinations, gynecological exams, and medical examinations appropriate to presenting complaint and history. He/she is also expected to do assessment and management plans on acute and chronic illnesses commonly seen in a primary care setting. r. A physician will be designated to provide general supervision of the nurse practitioner. All other licensed physicians employed by PATHS shall serve as alternate supervising physicians. In the absence of the designated supervising physician, any of the licensed physicians employed by PATHS may provide supervisory consultation, either in person or by telephone. s. Chart documentation of patient visits made by a nurse practitioner will be randomly reviewed by the Medical Director/Supervising Physician for evaluation of appropriateness of documentation, diagnosis, management and care plans, as well as to monitor for quality of care. The Medical Director/Supervising Physician will discuss with the nurse practitioner his/her findings and implement any necessary educational or remedial actions. t. Biennially, a nurse practitioner must complete forty (40) hours of continuing education in the area of specialty practice approved by one of the certifying agencies designated in 18 VAC 90-30-90. 9. Prescriptive Authority: a. A nurse practitioner may prescribe drugs pursuant to Regulations for Prescriptive Authority, Title of Regulations: 18 VAC 90-40-10 et seq., Statutory Authority: 54.1-2400 and 54.1-2957.01 of the Code of Virginia dated December 24, 2008. b. A nurse practitioner with prescriptive authority is required to obtain eight (8) hours of continuing education in pharmacology or pharmacotherapeutics for each biennium. Page 5 of 8
c. A nurse practitioner with prescriptive authority shall retain evidence of compliance and all supporting documentation for a period of four (4) years following the renewal period for which the records apply. d. A nurse practitioner with prescriptive authority shall submit a new practice agreement which meets the requirements of 18 VAC 90-40-90 with each renewal application if there has been a change in supervision, authorization, or scope of practice since the last practice agreement was filed or at any time a change in the primary supervising physician occurs. e. A nurse practitioner may order prescription drugs and devices, and dispense sample drugs under the following protocols: i ii. The drug or device is part of a medical treatment plan implemented for health care management as outlined in this document; The drug, device or category is listed in the practice agreement submitted to the Virginia Board of Nursing for authorization to prescribe; iii. The drug is not a controlled substance, schedule I; iv. A consultation with a physician, if made, must be noted in the patient s chart; v. Patient education is given regarding the drug or device; vi. vii. viii. ix. The prescription must be recorded in the patient s chart and include the nurse practitioner s signature; A current prescribing number must be noted on the prescription; All other applicable protocols in this document are followed during patient care management; All general policies regarding review, approval, setting, education, evaluation, medical records, supervision and consultation in these protocols are in force. f. A nurse practitioner will not prescribe the following: i. Controlled substances as defined by Federal Controlled Substances act 21 DSC 812 as schedule I; ii. Radioactive drugs; Page 6 of 8
10. Billing: All services rendered by the nurse practitioner shall be billed under the provider number of the supervising physician. If the Medical Director, for any reason, is no longer employed by PATHS, the CEO shall designate an Interim Supervising Physician until such time as a new Supervising Physician can be employed. Services rendered by the nurse practitioner will be billed under the provider number of the Interim Supervising Physician until a replacement is employed. This practice agreement has been reviewed and agreed upon by the parties below: / / FNP Name (Printed) Signature Date / / Supervising Physician Name Signature Date / / Alternate Supervising Physician Signature Date / / Alternate Supervising Physician Signature Date / / CEO Name (Printed) Signature Date Page 7 of 8
APPENDIX 1: Resources Dermatology: Fitzpatrick, MD, et al. (1997). Color Atlas and Synopsis of Clinical Dermatology (3 rd Ed). New York, NY; McGraw Hill, Inc. Habif, T.P. (1996) Clinical Dermatology: A Color Guide to Diagnosis Therapy (3 rd Ed). St. Louis, MO: Mosby-Yearbook, Inc. Diagnostic Studies: Breuninger, C.C. and Wittig, P. (2001) Diagnostics. Springhouse, PA: Springhouse Co. General Medicine: Braunwald, E., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L. and Jameson, J.L. (2002). Harrison s Manual of Medicine (15 th ed) New York, NY: Mcraw Hill, Inc. Ewald, G.A. and McKenzie, C.R. (1995). The Washington Manual (28 th Ed). Boston, MA: Little Brown and Co. Wilson, J.D., Braunwald, E., Isselbacher, K.J., Petersdorf, R.G., Marin, J.B., Fauci, A.S., and Root, R.K. (1992). Harrison s Principles of Internal Medicine (12 th Ed) New York, NY: McGraw Hill, Inc. General Urology: Gomella, L.G. (2000) The 5-minute Urology Consult. Philadelphia, PA: Lippincott, Williams & Wilkins. Walsh, P.C. Retik, A.B., Vaughan, E.D., Jr., and Wein, A.J. (1998) Campbell s Urology (7 th Ed) Philadelphia, PA: W.B. Saunders Co. Pediatrics: Griffiths 5-Minute Pediatric Consult Pharmacology: Physician s Desk Reference. (Current year) Montvale, NJ: Medical Economics Guide to Antimicrobial Therapy. (Current handbook) Sandford Tarascon Pocket Pharmacopaeia (2003 Deluxe Ed): Loma Linda, CA: Tarascon Publishing Procedures: Edmunds, M.W. and Mayhew, M.S. (1996) Procedures for Primary Care Practitioners. St. Louis, MO: Mosby Yearbook, Inc. Women s Health: Yougkin, E.Q. and Davis, M.S. (1994) Women s Health: A Primary Care Clinical Guide. Norwalk, CT: Appleton & Lange Page 8 of 8