Arnp Protocol Form – Fill Out and Use This PDF

ARNP P rotocol - (format example)

(Should be no more than 2 to 5 pages)

I.Requiring Authority:

A.Nurse Practice Act, Florida Statutes, Chapter 464

B.Florida Administrative Code, Rules Chapter 64B9-4 Administrative Policies Pertaining to Advanced Registered Nurse Practitioners

II. Parties to Protocol:

(Should only list one ARNP & one authorized supervising physician here)

A.(Name), ARNP, RN 9999999

ARNP Address 123 Street Anywhere, FL 12345

B.(Name of authorized supervising physician) title, Florida license number, DEA 999999

Physician Address 456 Avenue Anywhere, FL 12345

C.Practice Name

Practice Location

123 Main Street

Somewhere, FL 99999

III. Nature of Practice:

This collaborative agreement is to establish and maintain a practice model in which the nurse

practitioner will provide health care services under the general supervision of (name of authorized supervising physician, title).This practice shall encompass family practice and shall

focus on health screening and supervision, wellness and health education and counseling, and the treatment of common health problems. (Use appropriate description for your specialty and activities) Practice Location(s):

IV. Description of the duties and management areas for which the ARNP is responsible:

A.Duties of the ARNP:

The ARNP may interview clients, obtain and record health histories, perform physical and development assessments, order appropriate diagnostic tests, diagnose health problems, manage the health care of those clients for which she has been educated, provide health teaching and counseling, initiate referrals, and maintain health records. (Specific guidelines for patient care decision making may be referenced here. I.e., ARNP developed practice guidelines, professionally developed guidelines, text books, etc. Do not send these references to the Board of Nursing with protocol agreement.)

B.The conditions for which the ARNP may initiate treatment include, but are not limited to: Otitis media and externa

Conjunctivitis

Upper respiratory tract infections Sinusitis

C.Treatments that may be initiated by the ARNP, depending on the patient condition and judgment of the ARNP:

1.Suture of simple and complex lacerations not requiring ligament or tendon repair.

2.Incision and drainage of abscesses.

3.Removal of ingrown toenail.

ARNP Protocol - (format example)

D.Drug therapies that the ARNP may prescribe, initiate, monitor, alter, or order:

(ARNPs CANNOT PRESCRIBE CONTROLLED SUBSTANCES)

Any prescription medication which is not listed as a controlled substance and which is within the scope of training and knowledge base of the nurse practitioner.

-or – Antibiotics Antihypertensives Etc.

V. Duties of the Physician:

The physician shall provide general supervision for routine health care and management of common health problems, and provide consultation and/or accept referrals for complex health problems. The physician shall be available by telephone or by other communication device

when not physically available on the premises. If the physician is not available, his associate, (Name of Backup Physician), title, Florida license number/DEA #999999 (or other description of designated authorized supervising physician), will serve as backup for consultation,

collaboration and/or referral purposes.

VI. Specific Conditions and Requirements for Direct Evaluation

With respect to specific conditions and procedures that require direct evaluation, collaboration, and/or consultation by the physician, the following will serve as a reference guide:

Clinical Guidelines in Family Practice, X Edition, by Constance R. Uphold, ARNP, PhD, and Mary Virginia Graham, ARNP, PhD (or other reference text or practitioner created reference guide)

OR

The physician will be consulted for the following conditions:

3rd degree lacerations

Severe hypertension determined by _ Etc. (list appropriate conditions)

VII. All parties to this agreement share equally in the responsibility for reviewing treatment protocols as needed and no less than annually.

	(signature)	_		/		License # RN9999999
(printed name), ARNP					Date
	(signature)	_		/			License #XX 999999
	(printed name), title				Date	DEA # 999999
	(signature)	_		/			License #XX 999999
	(printed name), title				Date	DEA # 999999

(secondary physician, if applicable)

PLEASE NOTE:

Practicing ARNPs must file an entire protocol at the time of their biennial renewal or when there are changes with the Board of Nursing. Alterations or amendments should be signed by all parties and filed with the Board within 30 days.

The protocol and any amendments or changes are to mailed to the ARNP Department, Board of Nursing, 4052 Bald Cypress Way, Bin #C02, Tallahassee, FL 32399-3252. A copy for each review period should be kept by each party for a period of four years. The supervising physician is responsible for submitting a notice to the Board of Medicine that they have entered into a supervisory relationship with an ARNP.