ADVANCED PRACTICE NURSING
ADVANCED PRACTICE NURSING
WRITTEN COLLABORATIVE AGREEMENT
|A. |ADVANCED PRACTICE NURSE INFORMATION |
| |1. |NAME: | |
| |2. |ILLINOIS RN LICENSE NUMBER: | |
| | |ILLINOIS APN LICENSE NUMBER: | |
| | | | |
| | |FEDERAL MID-LEVEL PRACTITIONER DEA NUMBER: | |
| |3. |AREAS OF CERTIFICATION: | |
| |4. |CERTIFYING ORGANIZATION: | |
| |5. |CERTIFICATION EXPIRATION DATE: | |
| |6. |CERTIFICATION NUMBER: | |
| |7. | | |
| | |PRACTICE SITES: Family Christian Health Center | |
| |8. |CONTACT NUMBER: |708-596-5177 |
| | |FACSIMILE NUMBER: | |
| |
|B. |COLLABORATING PHYSICIAN INFORMATION |
| |1. |NAME: | |
| |2. |ILLINOIS LICENSE NUMBERS: | |
| |3. |PRACTICE AREA OR CONCENTRATION: | |
| |4. |BOARD CERTIFICATION (if any): | |
| |5. |CONTACT NUMBER: |708-596-5177 |
| | |FACSIMILE NUMBER: | |
|C. |ADVANCED PRACTICE NURSE COLLABORATING PHYSICIAN WORKING |
| |RELATIONSHIP |
| |1. |SCOPE OF PRACTICE |
| |Under this agreement, the advanced practice nurse will work with the collaborating physician (s) in an active practice to |
| |deliver health care services to patients at Family Christian Health Center. This includes, but is not limited to, the |
| |diagnosis, treatment and management of acute and chronic health problems; ordering, interpreting and performing laboratory |
| |and radiology tests; prescribing medications, including controlled substances, to the extent delegated; receiving and |
| |dispensing stock and sample medications; performing other therapeutic or corrective measures as indicated. |
| | |
| |This written collaborative agreement shall be reviewed and updated annually. A copy of this written collaborative agreement |
| |shall remain on file at all sites where the advanced practice nurse renders service and shall be provided to the Illinois |
| |Department of Financial and Professional Regulation upon request. |
| |2. |MEDICAL DIRECTION |
| |Physician medical direction is defined as collaboration with the Certified Nurse Practitioner in the following manner: |
| |(A) |Participates in the formulation of or approves of the use of standard clinical guidelines with the APN. These|
| | |guidelines must be in accordance with accepted standards of medical practice and advanced practice nursing |
| | |practice. |
| | |Such clinical guidelines include but are not limited to: |
| | |Clinical Guidelines in Family Practice—Uphold, |
| | |Graham |
| | |Nurse Practitioner’s Prescribing Reference |
| | |The Harriet Lane Handbook |
| | |Epocrates—online |
| | |Various National Organizational Guidelines |
| | |including, but not limited to: |
| | |Centers for Disease Control (CDC) |
| | |American College of Gynecologists & |
| | |Obstetricians (ACOG) |
| | |Department of Health and Human |
| | |Services |
| | | |
| | | |
| | | |
| | | |
| |(B) |Is on site at least once a month to provide medical direction and consultation; and |
| | | |
| |(C) |Is available through telecommunications for consultation on medical problems, complications, or emergencies or|
| | |patient referral. |
| | | |
| | | |
| |3. |COMMUNICATION, CONSULTATION AND REFERRAL |
| |The advanced practice nurse shall consult with the collaborating physician by telecommunication or in person as needed. In |
| |the absence of the designated collaborating physician, another physician shall be available for consultation. |
| |The advanced practice nurse shall inform each collaborating physician of all written collaborative agreements he or she has |
| |signed with other physicians, and provide a copy of these to any collaborating physician upon request. |
| |4. |DELEGATION OF PRESCRIPTIVE AUTHORITY |
| |Delegation of prescription authority by the collaborating physician is done according to state and federal guidelines and the |
| |APN may only prescribe controlled substances with a current controlled substance license. |
| | |
|WE THE UNDERSIGNED AGREE TO THE TERMS AND CONDITIONS OF THIS WRITTEN COLLABORATIVE AGREEMENT. |
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|Date:______________ |
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|Collaborating Physician Name___________________; Signature__________________ |
| |
|APN Name____________________; Signature__________________________ |
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|Date:______________ |
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|Collaborating Physician Name___________________; Signature__________________ |
| |
|APN Name_________________________; Signature______________________ |
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|Date:______________ |
| |
|Collaborating Physician Name___________________; Signature__________________ |
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|APN Name_________________________; Signature______________________ |
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