VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Certified Registered Nurse Anesthetist
Date Reviewed and Approved by PSB
Scope of Practice Approved
From ________________ To ____________________
(To be completed by Credentialing Staff only)
Name of Practitioner _______________________________________________________________________
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
On-Station Contract
Without Compensation (WOC)
On-Station Sharing Agreement
SETTING OF SCOPE OF PRACTICE: Check Appropriate Box
Nashville (Inpatient, Outpatient, ED, ICU, OR, Procedure Areas)
York (Inpatient, Outpatient, ED, ICU, OR, Procedure Areas)
Eligibility Criteria: To be eligible to request a scope of practice, the applicant must meet the following minimum
criteria (specialty specific):
1. Basic Education: Must be a graduate of a school of professional nursing approved by the appropriate
accrediting agency at the time the program was completed by the applicant
Must be a graduate of a school of anesthesia approved by the American Association of Nurse Anesthetists.
2. Minimum Formal Training
Certification by the Council on Certification of Nurse Anesthetists is a requirement for employment.
List certification number:
Date of certification:
Expiration Date:
3. Previous Experience: A letter of reference must come from a peer, department chair or program director with
whom the Certified Registered Nurse Anesthetists has been affiliated.
4. Board Certification: Must have a current RN and APN (Registered Nurse/Advanced Practice Nurse) license
and Certification by the Council on Certification of Nurse Anesthetists.
Applicant Name (print/type)
Page 1of 6
______________________________________________
Last 4 of SSN: _________
VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Certified Registered Nurse Anesthetist
CRNAs function under the general supervision of specifically 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.
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, multidisciplinary 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.
REQUESTED SCOPE OF PRACTICE
Core Checklist
YES
Performing the preanesthetic
history and physical assessment of
patients and documenting in the
Computerized patient Record
(CPRS) and/or the Pre-anesthetic
Evaluation and Anesthetic Record.
Developing and implementing an
anesthetic plan and documenting
in the CPRS patient file and on the
Pre-anesthetic Evaluation and
Anesthetic Record.
Initiating the anesthetic technique
which may include: general,
regional, local, and sedation.
NO
Level of
Autonomy
Nashville
Campus
York
Campus
RECOMMENDED APPROVAL
Recommended
approval by
Service Chief
PSB Approval
Yes
No
Yes
No
Date
4
3
2
General:
Inhalation
2
2
Intravenous
Applicant Name (print/type)
Page 2of 6
______________________________________________
Last 4 of SSN: _________
VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Certified Registered Nurse Anesthetist
REQUESTED SCOPE OF PRACTICE
RECOMMENDED APPROVAL
Recommended
approval by
Service Chief
Core Checklist
YES
NO
Level of
Autonomy
Nashville
Campus
York
Campus
Yes
No
PSB Approval
Yes
No
Date
Surgical Procedure Categories
Neurosurgical
Thoracic
Cardiac, open
Great vessels/major vascular
Abdominal
Organ transplant
Urological
Ophthalmologic
Otorhinolaryngology
Head and neck
Plastic
Oral/Maxillofacial
Geriatrics (greater than 70
years old)
Outpatient anesthesia
Maintaining anesthesia at
appropriate levels.
Support life functions during
the perioperative period.
Take immediate corrective
action while informing the
attending anesthesiologist and
surgeon ASAP of abnormal
patient responses.
Provide direct professional
observation and resuscitation
until the patient has regained
control of his/her vital
functions.
Maintain a complete and
legible documentation of the
perioperative course on both
the Anesthetic Record and the
progress notes in CPRS as
departmental policy.
Selecting, applying, and
inserting appropriate noninvasive and invasive
monitoring modalities for
continuous evaluation of the
patient's physical status.
Applicant Name (print/type)
Page 3of 6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
______________________________________________
Last 4 of SSN: _________
VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Certified Registered Nurse Anesthetist
REQUESTED SCOPE OF PRACTICE
CORE CHECKLIST
YES
NO
LEVEL OF
AUTONOMY
Facilitating emergence and
recovery from anesthesia
by selecting, obtaining,
ordering and administering
medications, fluids, and
ventilatory support .
Initiating and administering
respiratory support to
ensure adequate ventilation
and oxygenation in the
postanesthesia period by
interpreting arterial blood
gasses and assessment.
3
Performing the
postoperative evaluation
and physical assessment of
patients and documenting
in the Computerized patient
Record (CPRS) and
Anesthetic Record.
Maintenance of neuroaxial
and plexus infusions and
removal of neuroaxial and
plexus catheters.
Responding to emergency
situations inside and out of
the OR by initiating CPR
using basic or advanced
cardiac life support
techniques until a physician
becomes available and
then providing assistance
as needed.
Order Blood and Blood
Products after discussion
with Attending
Anesthesiologist.
Administer Blood and Blood
Products after discussion
with Attending
Anesthesiologist.
Secure and maintain airway
outside of the surgical suite
when needed.
3
Applicant Name (print/type)
Page 4of 6
NASHVILLE
CAMPUS
YORK
CAMPUS
RECOMMENDED APPROVAL
Recommended
Approval by
Service Chief
PSB Approval
Yes
No
Yes
No
Date
3
4
4
3
3
3
______________________________________________
Last 4 of SSN: _________
VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Certified Registered Nurse Anesthetist
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 National Formulary
medications.
Indicate exceptions below:
Controlled substances for schedule III, IV and V drugs subject to any limitations imposed by the
PA/NP’s registration or licensure and documentation of DEA Registration.
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
Antihistamine drugs
Antihypertensive drugs
Autonomic drugs: adrenergics, adrenergic blockers, and
skeletal muscle relaxants
Blood, blood products, and plasma expanders
Blood formation and coagulation: (includes anticoagulants,
anti-anemia agents - iron and B-12)
General anesthesia and adjuvant medications
Initiation of IV solutions without additives
Local anesthetics
Pulmonary specific drugs
Skin and mucous membrane agents: (Topical antiinfectives, anti- inflammatory, antipruritics,
astringents, emollients, demulcents, protectants, and
keratolytics agents)
Smooth muscle relaxants
Others as requested
____________________________________________
____________________________________________
____________________________________________
Applicant Name (print/type)
Page 5of 6
Requested
Autonomy
Level (1-5)
Service
Chief
Initials
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
______________________________________________
Last 4 of SSN: _________
VA TENNESSEE VALLEY HEALTHCARE SYSTEM
APPLICATION FOR SCOPE OF PRACTICE
PHYSICIAN ASSISTANT-NURSE PRACTITIONER-ADVANCED PRACTICE NURSE
SERVICE/SPECIALTY: Certified Registered Nurse Anesthetist
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
This Scope of Practice will be reviewed biannually and amended when necessary to reflect changes in
the duties and responsibilities, utilization guidelines and/or medical center policy.
CRNAs will be under the supervision of the anesthesiologists with current clinical privileges in the
Anesthesiology Service. The daily operating room schedule assignments determine the anesthesia care
team for each procedure, thus determining the supervising anesthesiologist. Anesthesiology Service
practices anesthesia using the anesthesia care team approach.
Reviewed/Signed:
I recommend scope of practice requested except as noted:
_____________________________________________
Ann Walia, M.D.
Chief, Anesthesiology Service
Date
_____________________________________________
Roger C. Jones, M.D., FACP
Date
Interim Chief of Staff/Chair Professional Standards Board
Approve/Disapprove PSB Recommendation
_____________________________________________
Juan Morales, RN, MSN
Health System Director
Applicant Name (print/type)
Page 6of 6
Date
______________________________________________
Last 4 of SSN: _________