STANDARD CARE AGREEMENT



STANDARD CARE AGREEMENT

I. Statement of Services

A family nurse practitioner provides holistic health and wellness care to patients of all ages. The nurse practitioner is legally authorized to diagnose, order laboratory work, x-rays and prescribe medications. The nurse practitioner can work either independently or in collaboration with a health care team.

II. Incorporation of New Technology or New Procedures

Technologies and procedures must be consistent with the scope of practice in the ORC 4723.43; OAC 4723-8-02. The nurse practitioner will identify new technologies and provide new procedures that may aid in improvement of patient care. Proper documentation of technologies and procedure will be provided and maintained by the office staff. Continuing education will be completed by the nurse practitioner to enable the most current technologies and procedures to be preformed.

III. Quality Assurance Provisions

A. Criteria for Referral/Consultation of a Client

The APN will determine when a referral or consultation is necessary. When necessary, the attending physician will be notified by telephone contact or spoken with directly, and the resulting plan of care will be documented in the patient’s record.

B. Procedures for Regular Review of Referrals to Other Health Professionals and Chart Reviews

A random selection of patient records and patient referrals will be selected at least annually for review by the CNP and the collaborating physician of the health care facility. Care outcomes will be reviewed during this process.

C. Policy of Care of Infants under the age of two months not applicable

D. Policy for Coverage of Absences

In the event of a planned or unplanned absence by the APN, scheduled patients will be rescheduled.

E. Policy for Resolution of Clinical Disagreements

Should a disagreement arise between the APN and the collaborating

physician regarding diagnosis or treatment, one or more of the following

means for resolution shall be followed:

1. Consult with physicians within the practice.

2. Refer to current professional literature appropriate to the area of question.

3. Consult with a specialist in the area of question.

F. Arrangement Regarding Reimbursement

Current state and federal laws governing reimbursement will be adhered to.

G. Review and Renewal of the Standard of Care Agreement (SCA)

The SCA will be reviewed annually. Amendments will be made prior to the renewal of the agreement.

H. Review and Renewal of Hourly Wage and Benefits

The hourly wage and benefits will be reviewed annually. Amendments will be made prior to the renewal of the agreement.

IV. Prescriptive Authority

The APN who holds a valid certificate to prescribe (including an externship CTP) may prescribe in accordance with Sections 4723.48 through 4723.485, Ohio Revised Code, the rules of the Board of Nursing, and within the formulary made available by the Ohio Board of Nursing.

A. Availability of Timely and Direct Evaluation of the patient by the physician:

The collaborating physician or designated physician colleague shall be notified by telephone or spoken to directly to discuss the patient in order to ensure timely and direct evaluation of the patient within 24 hours.

B. Formulary Compliance

The APN who holds a Certificate to Prescribe (including an externship CTP) may prescribe medicines as allowed by the formulary established by the committee on Prescriptive Governance and made available by the Ohio Board of Nursing:

1. The APN may prescribe within her scope of practice, as indicated by education preparation.

2. The signature of the APN and the collaborating physician on the SCA implies acceptance of the formulary as written.

3. Any restrictions to selected drugs within the formulary, as agreed upon by the APN and the physician shall be indicated in the addendum to this SCA.

4. Specific drugs, such as opiates, antidepressants and steroids, must be reviewed as indicated by the formulary.

C. Quality Assurance Provisions Related to Prescriptive Authority:

The APN and the collaborating physician will review a random sample written prescriptions at least semi-annually.

V. Addendum

Selected off formulary medications used to treat conditions not approved by the FDA, but in collaboration with the physician.

1. Trazadone: prescribe for sleep

2. Celebrex: prescribed for headaches

3. Prozac: prescribed for PMS

4. Sinemet: prescribed for restless leg syndrome

5. Cymbalta: prescribed for fibromyalgia

6. Neurontin: prescribed for diabetic neuropathy

7. Lyrica: prescribed for chronic pain

Pursuant to Ohio Revised Code Section 4723.431 the undersigned have agreed to the terms and conditions of the aforementioned SCA contains all necessary provisions, required by law, and any changes or amendments to the SCA must be agreed to by the undersigned, in writing, and incorporated as part of the SCA.

Collaborating Parties

CRNP

Lisa J. King CRNP ________________________Date__________

3555 Possum Run Road

Mansfield, Ohio 44903

419-756-5472 or 419-565-0024

Physician

Doctor John Doe, MD ________________________Date_________

5555 Somewhere Drive

Anywhere, Ohio 44444

419-555-5555

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