Org. Name______
City______State___
In compliance with statue #______(in Arkansas it’s 17-105-101), a copy of this agreement will be kept on file at all ______(your state)practice sites and with the ______(your state)State Board of Medicine Board. This agreement will go in to effect
It will be updated as necessary to reflect changes in the practice.
Physician Assistant Protocol and Delegation of Services Agreement for:
______(your PA’s name)
RHC #1 Name______
Address______
______
Ph.______
FAX______
RHC #2 Name______
Address______
______
Ph.______
FAX______
RHC #3 Name______
Address______
______
Ph.______
FAX______
Supervising Physician: ______License # ______
Back-UP Physician: ______License # ______
Services to be performed by physician assistant in the medical practice of supervising physician:
+Obtain Chief Complaint
+Obtain History
+Perform comprehensive and problem oriented Physical
+Order and interpret lab tests and radiographic studies with final interpretation by supervisor and/or radiologist
Page 1 Physician Assistant Protocol
+Develop problem list
+Formulate and institute Care Plan
+Patient education
+Patient follow-up and referrals as needed
+Hospital rounds, including admission, writing orders and progress notes
+Discharge Planning
+Evaluates and Clarifies clinical conditions
Procedures requiring onsite physician supervision:
Procedures to be performed by physician assistant in the medical practice of supervising physicians:
+Start IV’s
+Venipunctures
+Removal of uncomplicated skin lesions, if necessary, including use of cryo (freezing), for example. The PA will also Biopsy any such skin lesions as seen necessary for the treatment care plan of the patient, which is to be collaborated with the supervising/back up physician for diagnosis and treatment, pending biopsy results.
+Medication injections, may include, for example:
Intramuscular ( steroids, antibiotics)
Subcutaneous(epinephrine, insulin)
+Incision and Drainage of Superficial Abscesses
+Placement of urinary catheter
+Flushing of PIC lines or Ports
+Wound Care, documentation and Dressings
+Pap smears
+Proctoscopes and Pelvic exams
Medications to be prescribed by the physician assistant:
+All non-controlled medications with the following exceptions:
Chemotherapeutic agents
Thrombolytics agents (These do NOT include Anti-Thrombotic medications such as Heparin, Lovenox, Coumadin, ect.
As these are included in the PA prescribing Protocol.
+Controlled medications within Schedules III, IV, V
Page 2 Physician Assistant Protocols
Type and Frequency of Supervidion by the Supervising Physician:
The physician assistant’s delegated scope of practice has the following restrictions;
-activities in which diagnosis, treatment or management
exceeds PA’s level of competence, training or skill outside
the scope of the physician’s level.
The Supervising Physician or his Back-up Supervising Physician will be onsite or available at all times to the physician assistant. One of these physicians will be withing a driving radius of 60 minutes of the physician’s assistant and would always be available via phone.
The physician assistant will not practice if the Supervising Physician or the Back-up Supervising Physician is physically absent or not physically available within 60 minutes.
Process of Evaluation by Supervising Physician and Back-up Supervising Physician:
+100% review and countersign the documentation of all physician assistant patient encounters within the first 120 days of authorization to provide care in accordance with Community Medical Center’s bylaws.
+There unto after the first 120 days, the Supervising Physician will review and countersign 10% of all physician assistant’s patient encounters in the Clinic setting.
+100% review and countersign of all inpatient physician assistant encounters in compliance with the by-laws and rules and regulations of CMCIC.
+100% review of all procedures performed by the physician assistant within the first 120 days following authorization to provide care in accordance with CMCIC hospital by-laws.
Local ambulance service will be used to transport medical emergencies when supervising or back-up physician in not on site. Progress notes written by the physician assistant for patients who require hospital admission or transfer to the Emergency Department of CMCIC at Calico Rock will be countersigned by Supervising Physician within 24 hours.
Page 3 Physician Assistant Protocols
Org Name______
Physician Assistant Protocols
Printed Name of PA:______, PA-C
______
Signature of PADate
Printed Name of Supervising Physician: ______
______
Signature of Supervising PhysicianDate
Printed Name of Back Up Supervising Physician:______
______
Signature of Back Up Supervising PhysicianDate
Printed Name of Back-UP Supervising Physician: ______
______
Signature of Back Up Supervising PhysicianDate
Signature of Arkansas State Medical Board:
______
PA ChairmanDate