LAKE COUNTY HEALTH DEPARTMENT
AND
COMMUNITY HEALTH CENTER
NURSE PRACTITIONER OR CERTIFIED NURSE MIDWIFE/PHYSICIAN
WRITTEN COLLABORATIVE AGREEMENT
I. Nurse Practitioner or Certified Nurse Midwife Information
1. Name
2. Illinois RN License Number:
3. Area of Certification
4. Certifying Organization:
5. Certification Expiration Date:
6. Certification Number
7. Practice Site Name and Address
II. Physician(s) Information
1. Name:
2. Illinois Registration Number
3. Board Certification Area
4. Certifying Organization
5. Practice Site Name and Address
III. Guidelines of Collaboration
In this agreement, the term “collaboration” means that the nurse practitioner or certified nurse midwife works with the collaborating physician(s) in an active practice to deliver health care services in accordance with the nurse practitioner’s or certified nurse midwife’s education and experience. These services are provided under medical direction in jointly formulated and approved guidelines as defined by the Illinois Nursing and Advanced Practice Nursing Act. The physician(s) shall file with the Department of Professional Regulation notice of delegation of prescriptive authority and termination of such delegation.
IV. Nurse Practitioner – Physician Relationship
The physician and nurse practitioner or certified nurse midwife shall consult with each other either by telecommunication or in person as needed. The physician must be on site at least once a month to provide medical direction and consultation.
The nurse practitioner or certified nurse midwife shall inform each collaborating physician of all written collaborative agreements he or she has signed with other physicians, and provide a copy of these to any collaborating physician upon request.
V. General Nurse Practitioner or Certified Nurse Midwife Services
· Perform comprehensive physical assessments
· Provide services related to health maintenance and promotion
· Establish diagnoses for common short-term and chronic stable health conditions
· Order, Interpret, and perform laboratory and radiology tests
· Provide stock and sample medications
· Perform other therapeutic or corrective measures as indicated
· Refer patients to licensed physicians or other health care providers as indicated
· Provide urgent care as indicated
· Provide Prenatal care and Family Planning services
· Provide Well-Child care, including screening and immunizations
VI. References and Guidelines
The nurse practitioner or certified nurse midwife may use, but is not limited to, the following references, texts, or guidelines in providing care:
Clinical Guidelines in Family Practice by Uphold and Graham, 3rd Edition. Additional protocols based on state code, grant requirements or special needs such as Family Planning, Sexually Transmitted Disease, or prenatal are established and located in the specific clinic. These guidelines define criteria for specific conditions and clear treatment plans. These guidelines specify when to consult with a physician and all physicians, NPs and CNMWs are expected to be familiar with these criteria.
VII. Prescriptive Authority
a) A collaborating physician may, but is not required to, delegate limited prescriptive authority to an advanced practice nurse as part of a written collaborative agreement. This authority may, but is not required to, include prescription of legend drugs and legend controlled substance categorized as Schedule III, IV, or V controlled substances, as defined in Article II or the Illinois Controlled Substance Act.
b) To prescribe Schedule III, IV, or V controlled substance under this Section, an advanced practice nurse shall affix the collaborating physician’s DEA number to, and individually sign, the appropriate prescription form containing the printed names of the advanced practice nurse and collaborating physician in accordance with the written collaborative agreement. Medication orders shall be reviewed periodically by the collaborating physician.
c) The collaborating physician shall file with the Department notice of delegation of prescriptive authority and termination of such delegation, in accordance with rules of the Department.
VIII. Mutually agreed upon restriction other than those listed above (if more so state).
This agreement will remain in effect indefinitely EXCEPT
1. Either party may submit a written notice of revocation to the other. Such notice or revocation must be sent at least 30 days before the effective date of the revocation and a copy must be sent simultaneously to the Medical Director of the LCHD/CHC.
2. If either party ceases to be an employee of the LCHD/CHC, this agreement will terminate automatically on completion of the final day of employment.
Signature:
APN:______Date:______
Physician:______Date:______
CHECK ONE BOX AND BOTH PARTIES MUST INITIAL
o Limited prescriptive authority is delegated to the nurse practitioner or certified nurse midwife and includes delegation of prescription of controlled substances categorized as schedule III, IV, and V.
NP Initials: ______Doctor Initials: ______
o Limited prescriptive authority is delegated to the nurse practitioner or certified nurse midwife but excludes delegation of prescription of controlled substances categorized as schedule III, IV, and V.
NP Initials: ______Doctor Initials: ______
9/27/00