DELEGATED-SUPERVISED PRACTICE AGREEMENT

(Advanced Practice Nurse)

The purpose of this document is to establish the delegated/supervised practice between the undersigned Physician(s) and Advanced Practice Nurse (APN), specifically a Certified Nurse Midwife (CNM) or Certified Nurse Practitioner (CNP):

______

Physician(s) License Number

______

Advanced Practice Nurse License Number

As defined, a Certified Nurse Midwife (CNM) is “an individual licensed as a registered professional nurse under part 172, Act 368 or 1978 who has been issued a specialty certification in the practice of nurse midwifery by the board of nursing under section 17210”.

A Certified Nurse Practitioner (CNP) is “an individual licensed as a registered professional nurse under part 172, Act 368 or 1978 who has been issued a specialty certification as a nurse practitioner by the board of nursing under section 17210”.

The full document referenced above can be accessed at the following URL.

http://legislature.mi.gov/doc.aspx?mcl-Act-368-of-1978

APN’s provide nursing care as an independent function. However, the provision of delegated medical care requires the supervision of the delegating physician.

I ______delegate to ______the authority to write prescriptions, as part of his/her practice at ______effective

______. The APN will not be allowed to order or call in Schedule 2 medications.

  1. Delegation of this responsibility and authority is written in accordance with the Michigan Public Health Code (1978 P. A. 368) including but not limited to Section 16215(s): 17048(4); 17210(2).
  1. Services to be provided independently to patients within the scope and skill level of the APN named above and include:

·  Health maintenance examinations

·  Management of normal pregnancies

·  Women’s health management

·  Health counseling

·  Management of acute illness

  1. Documented evidence of delegation and/or supervision as above will occur.
  1. The supervising physician(s) named above, agrees to:

·  Evaluate and monitor the APNs practice and provision of medical care services

·  Delegate tasks in accordance with law and regulation and within the knowledge and experience of the APN

·  Be available on site or by telephone consultation during hours of operation and conduct at least one quarterly face to face meeting

·  Be available for record review when appropriate and complete a documented 10 (ten) chart audit per quarter

  1. The named above, agree to:

·  Prescribe as delegated and consult when needed for those medications not approved in the prescriptive authority agreement

·  Document consultation and referral with physician in progress notes

·  Participate in peer review processes as stipulated in employment contracts, Cherry Street Health Services policies and procedures and applicable job descriptions

·  Consult with the supervising physician on a regular basis and as needed to discuss management plans as clinically indicated

·  Obtain and document consultations and the resulting care plans in the medical record

·  Utilize appropriate references and clinical guidelines in determining the plan of care

  1. Each party is responsible and accountable for performing to the full and appropriate extent of his/her role and function in accordance with this, the individual’s professional level of knowledge and expertise, legitimate legal practice regulations as defined by the Michigan Public Health Code, and policies of Cherry Street Health Services.

Date:______

Date:______

Date:______

Date:______

Sources:

Michigan Public Health Code, Act 369 of 1978

American Academy of Family Practice, Guidelines on the supervision of certified nurse midwives, nurse practitioners and physician assistants. (2009)

11/2009

Revised 6/2010

Revised 10/2010

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