ARNP Protocol - (format
be no more than 2 to 5 pages)
- Requiring Authority:
- Nurse Practice Act, Florida Statutes, Chapter 464
- 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 Doctor here)
- (Name), ARNP, RN 9999999
(Name), MD, MX 999999, DEA 999999
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 Dr. Frank Farmer.
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
IV. Description of the duties and management areas
for which the ARNP is responsible:
A. Duties of 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
The conditions for which the ARNP may initiate treatment include,
but are not limited to:
C. Treatments that may be initiated by the ARNP, depending on
the patient condition and judgment of the ARNP:
media and externa
respiratory tract infections
- Suture of simple and complex lacerations not requiring
ligament or tendon repair.
- Incision and drainage of abscesses.
- Removal of ingrown toenail.
____________________________/ _______ License # RN9999999
Drug therapies that the ARNP may prescribe, initiate, monitor,
alter, or order:
CANNOT PRESCRIBE CONTROLLED SUBSTANCES)
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.
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, John R. Doctor,
MD, MX 999999 (or other description of designated doctor(s) or
groups), will serve as backup for consultation, collaboration and/or
VI. Specific Conditions and Requirements for Direct
VII. All parties to this agreement share equally in the
responsibility for reviewing treatment protocols as needed and no less
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
The physician will be consulted for the following conditions:
hypertension determined by ____
(list appropriate conditions)
(name), ARNP Date
________ License #ME 999999
(name), MD Date DEA # 999999
Practicing ARNPs must file a protocol at the time of 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.
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