Advanced Practice Registered Nurse Practice and Prescriptive Agreement

This practice and prescriptive agreement must be filled out, signed and kept at the Advanced Practice Registered Nurse’s (APRN, also identified as APN) place of employment per Minnesota Statutes Section 148.235, Subdivision 6, “Standards for written agreements; review and filing.” This agreement need not be filed with the Minnesota Board of Nursing or the Minnesota Board of Medical Practice.

  1. Semcac Medical Director and APN credentials

APN Name: Sarah J. Bohn, RN CNM

Degrees / Certification(s) / Specialty: Nurse Midwife

Practice Address: Semcac Family Planning Clinic 76 W 3rd St

Winona, MN55987

Practice Phone #: 507-452-4307

Other clinic locations: None

Experience: See Semcac Application, Resume, and CV

Semcac Medical Director:

Name: ______

Degrees / Certification(s) / Specialty: ______

  1. Description of Patient Population to be seen by APN

Check the location that describes the appropriate settings:

__ Clinic__ Other (specify) ______

Patient characteristic(s):

Ages:__ Adolescent__ Adult

Specify types of conditions: The APNs at Semcac Family Planning Clinic provide comprehensive reproductive health care to men and women. Care provided is limited to the services defined in the Semcac Medical Standards and Guidelines (MS&G) and include the following: preventive health care including annual exams and pap smears, contraception, detection and treatment of sexually transmitted infections, diagnosis and treatment of vaginitis and uncomplicated urinary tract infections, healthcare to transgender persons, preconception care, perimenopausal and post-menopausal care, and limited primary care conditions. Semcac APNs also provide patient education and counseling on a variety of health care topics.

APNs are invited by the Medical Director to make interval suggestions and recommendations. An open line of communication must be maintained between the Medical Director and APN to facilitate a smooth and efficient operation of the program. Any situation falling outside these specific parameters is to be referred to the Medical Director or an appropriate health care provider outside of Semcac for management.

Review of the APNs prescriptive practice will include communication with the Medical Director, annual medical quality assurance audits, quarterly chart audit by the Medical Director and review of the Medical Referral Log by the Medical Director.

  1. Prescriptive Authority

In this section, indicate the categories of drugs and/or devices which may be prescribed by the APN including and limitations to these categories.

__ See attached document.

  1. Termination or suspension of this agreement

In the event this agreement is terminated, continuity of care will be maintained by other APNs as indicated.

  1. Renewal Requirement(s):

This agreement shall be officially reviewed, renewed and signed at a minimum of annually from the date of signature. We the undersigned agree to review this document on __Jan 1, 2017_____. By our signatures we agree to follow the parameters specified above.

APN:

Name: ______Sarah Bohn, CNM______

Address: ___76 West 3rdSt Winona, MN 55987______

Phone: ____507-452-4307______

Signature: ______Date: ______

Medical Director:

Name:______

Signature: ______Date: ______