COLLABORATIVE PRACTICE AGREEMENT - midwest-site



COLLABORATIVE PRACTICE AGREEMENT

For use with Advanced Practice Nurse practicing at

SHALOM HEALTH CARE CENTER, INC.

Shalom Health Care Center, Inc.

Primary Care Clinic Farrington Elementary School Clinic

3400 Lafayette Road, Suite 200 4326 Patricia Street

Indianapolis IN 46222 Indianapolis IN 46222

Gambold Middle School Clinic Northwest High School Clinic

3725 Kiel Avenue, Room105 5525 W. 34th Street, Room 179

Indianapolis IN 46224 Indianapolis IN 46224

Advanced Practice Nurse

Complete Name:

Home Address and Telephone:

Work Address and Telephone: 3400 Lafayette Road

Indianapolis, IN 46222

License: RN License

Expires:

Certification: Pediatric Nurse Practitioner

Physician

Complete Name:

Home Address and Telephone:

Work Address and Telephone: Shalom Health Care Center, Inc.

3400 Lafayette Road, Suite 200

Indianapolis, IN 46222

317-291-7422

License:

Certification: M.D.

Advanced Nurse Practice Clinics

The Northwest High School Clinic of the Shalom Health Care Center, Inc. is housed in the Indianapolis Public School Corporation. The clinic manages children in the preadolescent and adolescent ages ranges. It is anticipated that 200 patients will be seen weekly.

Scope of Practice

This Collaborative Practice Agreement entered into 20th day of June, 2008, by and between Dr. Dannee J. Neal, physician duly licensed to practice medicine in the state of Indiana (hereinafter “Physician”), and Beth Pickens, advanced practice nurse, PNP duly licensed to practice advanced nursing as a pediatric nurse practitioner. The pediatric nurse practitioner and family physician will work together both independently and together as members of the health care team.

Beth Pickens will function in the role of pediatric nurse practitioner. This PNP will adhere to Indiana Board of Nursing Rules and Regulation (LSA Document 94-39) and to the standards defined in Scope of Practice for Primary Care by the American Nurses Association.

Dr. Dannee J. Neal will function in the specialty of family medicine. This physician will adhere to the scope of practice delineated in the Indiana Medical Practice Act. The physician will be on call to the ANP on the days Shalom Health Care Center, Inc. is open. Any patient needing a physician evaluation will be referred to Dr. Dannee J. Neal.

The scope of practice of the PNP at Shalom Health Care Center, Inc. will include the following:

1. Conduct comprehensive physical assessment.

2. Establish diagnoses for common short-term acute illness and uncomplicated chronic illnesses.

3. Order, perform, and interpret laboratory tests.

4. Prescribe medications.

5. Order radiologic procedures.

6. Refer patients to appropriate physicians and other health care providers at appropriate agencies.

7. Provide health maintenance and promotion.

8. Provide client education.

9. Institute emergency care.

Insurance

APN, in provision of her duties as a pediatric nurse practitioner shall be acting as an employee or Shalom Health Care Center, Inc. and as such, Shalom Health Care Center, Inc. shall provide medical malpractice insurance so as to qualify the APN as a provider under the Indiana Medical Malpractice Act (I.C. 27-12 et seq.).

Dr. Dannee J. Neal, MD, shall carry, as an employee of Shalom Health Care Center, Inc., medical malpractice insurance with those limits to qualify the providers under the Indiana Medical Malpractice Act (I.C. 27-12) and the physician agrees to be and remain a qualified provider thereunder.

Collaborative Responsibilities of Nurse Practitioner and Physician

Nurse Practitioner

1. Promote patients’ health.

2. Manage patients’ non-complicated acute and stable chronic conditions. Refer clients as necessary to Dr. Dannee J. Neal or other designated physicians at other agencies.

3. Initiate weekly communications with Dr. Dannee J. Neal.

4. Inform Dr. Dannee J. Neal on a weekly basis about medication use.

5. Work as part of collaborative clinic team.

Physician

1. Accept referrals from Shalom Health Care Center, Inc.

2. Meet with nurse practitioner on a weekly basis.

3. Manage patients with more complex conditions.

4. Be available on call during Shalom’s clinic hours by pager or phone. In the event of vacation or other time off, Dr. Dannee J. Neal will make every attempt to continue to be available by phone or pager. When this will not be possible, coverage will be arranged in advance to be provided by another physician licensed in the state of Indiana. The nurse practitioner will receive notification of this well in advance of the absence, including the covering physician’s name, credentials and contact information.

Prescriptive Authority

Beth Pickens, PNP, because of her skill, training and competence, has the authority to administer, dispense, and prescribe drugs and provide treatment within the scope of practice for a pediatric nurse practitioner.

Beth Pickens, PNP, is permitted to authorize pharmacists to fill prescriptions, including telephone prescriptions as defined in the law. Such prescriptions may be forwarded or transmitted to the pharmacist by the ANP, a registered professional nurse or other authorized agent.

All services performed pursuant to the Agreement shall be performed in a manner consistent with rules and regulations governing physician practices and advance nursing practices in Indiana.

The Agreement shall be applicable with respect to services provided within the scope of responsibility of a pediatric nurse practitioner and shall not be valid unless and until acknowledged by Dr. Dannee J. Neal, MD.

Quality Assurance

Reviews will occur with the nurse practitioner and physician to review prescribing and management practices. The physician will review charts with the nurse practitioner on a weekly basis. There will be a random sampling on 5% of the charts during that time period for the physician and nurse practitioner to evaluate prescriptive privileges.

This Agreement can be terminated at any time by either physician or advance nurse practitioner by written notice to the other. The party terminating such Agreement shall simultaneously provide a copy of termination to the Executive Director of Shalom Health Care Center, Inc.

This Agreement will be reviewed yearly and must be renewed every two years for the Indiana State Board of Nursing. Any changes with this agreement within those two years must be submitted to the Indiana State Board of Nursing.

Physician: Date:

Advanced Nurse Practitioner: Date:

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