VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Anesthesiology Pain Management Clinic
Date Reviewed and Approved by PSB
Scope of Practice Approved
From _________________ To ________________________
(To be completed by Credentialing Staff only)
Practitioner Name: _______________________________________________________________________
Last
First
Middle
TYPE OF REQUEST (Check Appropriate Box)
Initial
Biennial Renewal
Change in Scope of Practice
Change in Category of Staff Membership
CATEGORY OF STAFF MEMBERSHIP (Check Appropriate Box)
Full Time Staff
On-Station Fee Basis
Part Time Staff
Off-Station Fee Basis
Without Compensation (WOC)
On-Station Contract
On-Station Sharing Agreement
ELIGIBILITY CRITERIA. To be eligible to request a scope of practice, the applicant must meet the following minimum criteria
(specialty specific):
1.
Basic Education
Graduation with degree from an accredited program for physician assistants
Graduation with degree from an accredited program for advance practice nurses
2.
Board Certification
Physician Assistants
National Commission and Certification of Physician Assistants (NCCPA)
Other: ____________________________________
Advance Practice Nurses
American Nurses Credentialing Center (ANCC)
American Academy of Nurse Practitioners (AANP)
SETTING FOR SCOPE OF PRACTICE (Check Appropriate Boxes)
Nashville
York
CBOC Specify Site.
Contract Clinic (Outpatient) Specify Site.
LEVEL OF AUTONOMY: Non-physician clinical providers (clinical pharmacy specialists, nurse practitioners, physician assistants,
social workers, etc.) function under the general supervision of specially designated physicians. They provide care as agents of those
physicians and the supervisory physician retains responsibility of the medical appropriateness and correctness for all orders written
and care delivered.
Applicant Name (print/type)
______________________________________________
Last 4 of SSN: _________
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VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Anesthesiology Pain Management Clinic
Five (5) levels of autonomy are recognized and defined below:
1.
Functioning within a multi-disciplinary team - entries reflect team consensus, defined roles and authority, and
for which there is physician approval. Such would include ward teams, multi-disciplinary assessment teams, and
some clinical specialist coordinators.
2.
Direct clinical supervision - provider functions under immediate oversight, and entries/orders must be co-signed
or otherwise approved before the patient is cleared to leave the area.
3.
Proximate supervision - the provider is functioning under supervision and co-signature or approval (if required)
is obtained within a discrete time interval, normally 24 hours.
4.
Protocol - hospital approved and delegated authority for monitoring and /or protocol assessment and treatment.
5.
Autonomous supervision - concerns the global management of the patient and care; notification and review of
individual actions by the supervisor is not required. However, supervising physician review is required monthly
of 5% or 30 charts, whichever is largest. Peer review is required quarterly.
REQUEST FOR CORE SCOPE OF PRACTICE
Instructions:
Supervisor is to shade the Setting block of any activity that may not be performed prior to forwarding the document to the provider.
Provider is to complete all of the Requested Activities and Settings columns that are not shaded.
A shaded block indicates that the procedure/activity may not be requested for that site/setting.
REQUESTED
ACTIVITIES
Requested
YES NO
DESCRIPTION
Level
of
Autonomy
1-5
Perform history and physical
examinations on new inpatients
5
Perform history and physical
examinations on new outpatients
Prescribing medications within defined
scope of practice
Ordering diagnostic studies such as laboratory
tests, x-rays, electrocardiograms
Initiating requests for consultations
Making daily rounds to observe and record
each patient’s medical progress, updating and
summarizing medical records, changing orders
when appropriate, and notifying the responsible
physician of significant changes in the patient’s
condition
5
Applicant Name (print/type)
SETTINGS
N = Nashville
Y = York
O = Other – Specify
INP = Inpatient
OPT = Outpatient
N Y O INP OPT
RECOMMENDED APPROVAL
Supervisory
Physician
YES
NO
Service /
Section
Chief
YES
NO
PSB
YES NO
5
5
5
5
______________________________________________
Last 4 of SSN: _________
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VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Anesthesiology Pain Management Clinic
REQUESTED
ACTIVITIES
Requested
YES NO
DESCRIPTION
Making interim summaries of the
patient’s medical record
Dictating discharge summaries
Providing education and counseling of
patients and families in preventive
care, medical conditions, and use of
prescribed treatments and drugs
Attend and/or represent team in
treatment team meetings
Approve (sign) treatment team plan
Screen patients to determine need for
hospitalization
Order oxygen therapy
Order aerosolized breathing treatment
Order diets
Order home health, RCH, and nursing
home referrals
Perform ID, SQ, IM, or IV injections
Start IV solutions
Administer IV medications
Order and perform wound dressing
Administer topical/local anesthesia
Obtain and document patient’s
informed consent and advance
directives in accordance with the
practitioner’s scope of practice
Perform BCLS
Initiate ACLS
Treatment of acute respiratory failure
Treatment of life-threatening injuries
Conduct research
Instruction of medical and allied
healthcare students
Administrative duties such as TQI,
peer review, PSB and various
committees
Take and record medication history
Formulate patient treatment plans
Evaluate patient response to
medication therapy
Applicant Name (print/type)
Level
of
Autonomy
1-5
SETTINGS
N = Nashville INP = Inpatient
Y = York
OPT = Outpatient
O = Other - Specify:
N
Y
O
INP
OPT
RECOMMENDED APPROVAL
Supervisory
Physician
YES
NO
Service /
Section
Chief
YES
NO
PSB
YES
NO
5
5
5
5
5
4
5
5
5
5
5
5
5
5
5
5
5
5
3
3
3
4
5
5
5
5
______________________________________________
Last 4 of SSN: _________
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VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Anesthesiology Pain Management Clinic
Provide pharmacologic and
pharmacokinetic consultation
Assess medication adherence
Discontinue medications
Establish therapeutic end point of drug
therapy
Utilize mental status exam, AIMS
exam and psychiatric interview
techniques to assess clinical response
Treat acute dystonia
Treat overdoses, poisonings and
toxicities
*Others—see supplemental checklist
that follows
REQUEST FOR SUPPLEMENTAL SCOPE OF PRACTICE
Instructions. Provider to list/describe in the first column any additional activities not listed in the core scope of practice section. The
provider is also to complete the Requested and Setting columns for each supplemental activity requested.
REQUESTED
DESCRIPTION
Applicant Name (print/type)
Requested
YES
NO
Level
of
Autonomy
1-5
SETTING
N = Nashville
Y = York
O = Other - Specify:
INP = Inpatient
OPT = Outpatient
N
Y
O
INP
RECOMMENDED APPROVAL
OPT
______________________________________________
Supervisory
Physician
YES
NO
Service /
Section
Chief
YES
NO
PSB
YES
NO
Last 4 of SSN: _________
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VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Anesthesiology Pain Management Clinic
MEDICATION PRESCRIBING AUTHORITY
No medication orders of either non-controlled or controlled substances may be written.
Inpatient and outpatient non-controlled substances that are approved TVHS formulary medications. Indicate exceptions below:
Controlled substances schedule II through V drugs subject to any limitations imposed by the PA/ANP State licensure.
Indicate any limitations or exceptions below:
Prescribing authority will be divided into the listed levels of autonomy (see explanation above).
Categories
Analgesics, antipyretics, and anti-inflammatory drugs (except controlled drugs)
Anti-convulsants
Anti-depressants
Antihistamine drugs
Anti-infective agents (PO) only: (includes antibiotics, antifungals, antivirals,
antituberculars)
Antitussives, mucolytics, expectorants
Anxiolytics, Sedatives, Hypnotics: (except controlled drugs)
Autonomic drugs: adrenergics, adrenergic blockers, and skeletal muscle relaxants
Blood formation and coagulation: (includes anticoagulants, anti-anemia agents - iron and
B-12)
Gastrointestinal drugs
Hormones and Synthetic substitutes: (adrenals, androgens, estrogens, antidiabetic agents,
parathyroid, pituitary, progestins, thyroid and antithyroid agents, and steroids)
Initiation of IV solutions without additives
Local anesthetics
Pulmonary specific drugs
Skin and mucous membrane agents: (Topical anti-infectives, anti- inflammatory,
antipruritics, astringents, emollients, demulcents, protectants, and keratolytics agents)
Smooth muscle relaxants
Vitamins
List others below with the exception of Antineoplastic Drugs which are to be
requested as a supplemental scope of practice.
Applicant Name (print/type)
______________________________________________
Requested
Autonomy
Level 1-5
Supervising
Physician
Initials
Service
Chief
Initials
Last 4 of SSN: _________
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VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Anesthesiology Pain Management Clinic
I ACKNOWLEDGE THAT I HAVE BEEN FURNISHED WITH A COPY OF THE CURRENT MEDICAL STAFF
BYLAWS, AND I HEREBY AGREE TO ABIDE BY THEM. I ALSO AGREE TO PROVIDE CONTINUOUS CARE TO
PATIENTS ASSIGNED TO ME AND ARRANGE FOR THE TRANSFER OF CARE AS APPROPRIATE. I CERTIFY
THAT I HAVE HAD APPROPRIATE EXPERIENCE AND/OR TRAINING AND I AM PHYSICALLY AND MENTALLY
COMPETENT TO PERFORM THE SCOPE OF PRACTICE REQUESTED.
YES
NO
________________________________________________/___________________
(Applicant’s Signature)
Date
_______________________________________________/____________________
(Type/Print Name)
Date
I recommend scope of practice requested:
____________________________________________/__________
Supervising Physician
Date
_________________________
Printed Name
_____________________________________________/_________
Alternate Supervising Physician
Date
________ _________________
Printed Name
_____________________________________________/_________
Ann Walia, M.D.
Date
Chief, Anesthesiology Service
____________________________________________/___________
Roger C. Jones, M.D., FACP
Date
Interim Chief of Staff/Chair, Professional Standards Board
Approve/Disapprove PSB Recommendation
___________________________________________/____________
Juan A. Morales, RN, MSN
Date
Health System Director
Applicant Name (print/type)
__________________
Effective no later than
______________________________________________
Last 4 of SSN: _________
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