P : A

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PROTOCOL: ADVANCED PRACTICE NURSING
Service Line:
Add appropriate service line here
Protocol
Number
PL xx-xxx-xx
Effective Date
Month/Year
Supersedes
Month/Year
Add name of protocol here in bold
Key Words: For search purposes, add appropriate key words
Practice Site Location(s)
Children’s
VUH
DOT
VMG Off-site locations
VMG
VPH
Other
Developed & Approved by
Name:
Title:
Date
Name:
Title:
Date
Name:
Title:
Date
Name:
Title:
Date
Table of Contents
I.
Population: ...................................................................................2
II.
Indications: ...................................................................................2
III.
Definitions: ...................................................................................2
IV.
Additional Competencies Required:.............................................2
V.
Assessment: ..................................................................................2
VI.
Diagnostic Data: ...........................................................................2
VII.
Differential Diagnosis: .................................................................2
VIII.
Goals of Treatment: ......................................................................2
IX.
Intervention/Treatment: ................................................................3
X.
Complications: .............................................................................3
XI.
Medications by Formulary: ..........................................................3
XII.
References: ................................. Error! Bookmark not defined.
©2012 Vanderbilt University. All rights reserved.
Inquiries: Center for Advanced Practice Nursing (615) 322-4664
Page 1 of 3
PROTOCOL: ADVANCED PRACTICE NURSING
Service Line:
Add appropriate service line here
Protocol
Number
PL xx-xxx-xx
Effective Date
Month/Year
Supersedes
Month/Year
Add name of protocol here in bold
Key Words: For search purposes, add appropriate key words
I.
Population:
Define target patient population here
II.
Indications:
Insert brief statement regarding indication(s) for use of protocol.
III.
IV.
V.
VI.
Definitions:
A.
Insert definitions here if indicated for this protocol
B.
If there are no definitions, write “None” in this section.
Additional Competencies Required:
A.
Insert competency detail here if indicated for this protocol.
B.
If there are no Additional Competencies Required, write “None” in this
section.
Assessment:
A.
Physical Exam: describe typical physical exam findings for disease
process
B.
History: describe typical history findings for disease process
Diagnostic Data:
Describe typical diagnostic data to be obtained (lab, radiology, other diagnostics)
VII.
Differential Diagnosis:
List other possible diagnoses requiring “rule out” and/or further evaluation.
VIII. Goal(s) of Treatment:
Expected outcomes related to treatment of disease process
©2012 Vanderbilt University. All rights reserved.
Inquiries: Center for Advanced Practice Nursing (615) 322-4664
Page 2 of 3
PROTOCOL: ADVANCED PRACTICE NURSING
Service Line:
Add appropriate service line here
Protocol
Number
PL xx-xxx-xx
Effective Date
Month/Year
Supersedes
Month/Year
Add name of protocol here in bold
Key Words: For search purposes, add appropriate key words
IX.
X.
Intervention/Treatment:
A.
List specific interventions and treatments
B.
Include criteria for when to consult physician:
Complications:
List specific complications for disease process and treatment; include monitoring
criteria and specific interventions for complications
XI.
Medications by Formulary:
List medications by formulary typically used in conjunction with this procedure
(include pre-procedure medications and discharge medications)
XII.
References:
List relevant references used in the development of the protocol
Use APA format [for assistance, visit
http://owl.english.purdue.edu/owl/resource/560/01/]
©2012 Vanderbilt University. All rights reserved.
Inquiries: Center for Advanced Practice Nursing (615) 322-4664
Page 3 of 3
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