PROCEDURE: ADVANCED PRACTICE NURSING
Service Line:
Add appropriate service Line here
Procedure
Number
PC xx-xxx.xxx
Effective Date
Month/Year
Supersedes
Month/Year
Add name of procedure here in bold
(Provider must hold privileges to perform this procedure)
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 and/or 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.
Universal Protocol ....................................................................... 2
VII.
Anesthesia .................................................................................... 2
VIII.
Goals of Procedural Intervention ................................................. 3
IX.
Procedure ..................................................................................... 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
PROCEDURE: ADVANCED PRACTICE NURSING
Service Line:
Add appropriate service Line here
Procedure
Number
PC xx-xxx.xxx
Effective Date
Month/Year
Supersedes
Month/Year
Add name of procedure here in bold
(Provider must hold privileges to perform this procedure)
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 procedure.
III.
IV.
V.
VI.
Definitions:
A.
Insert definitions here if indicated for this procedure
B.
If there are no definitions, write “None” in this section
Additional Competencies Required:
A.
Insert competency detail here for this procedure.
B.
If there are no Additional Competencies Required, write “None” in this
section.
Assessment:
A.
Physical Exam: describe pre/post procedure assessment
B.
Documentation: describe required documentation for this procedure (preprocedure note, immediate post procedure note, procedure note, discharge
criteria post procedure)
Universal Protocol (UP):
Describe steps of the UP required for this procedure
VII.
Anesthesia:
List type of anesthesia (none, local, moderate/deep sedation, etc) to be used along
with contraindications, required monitoring, and documentation
©2012 Vanderbilt University. All rights reserved.
Inquiries: Center for Advanced Practice Nursing (615) 322-4664
Page 2 of 3
PROCEDURE: ADVANCED PRACTICE NURSING
Service Line:
Add appropriate service Line here
Procedure
Number
PC xx-xxx.xxx
Effective Date
Month/Year
Supersedes
Month/Year
Add name of procedure here in bold
(Provider must hold privileges to perform this procedure)
Key Words: For search purposes, add appropriate key words
VIII. Goal(s) of Procedural Intervention:
Expected outcomes related to the procedural intervention
IX.
X.
Procedure:
A.
List specific steps of the procedure (may include link to reference text
outlining procedural steps)
B.
Include criteria for when to consult physician:
Complications:
List specific potential complications for this procedure; 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 procedure
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