Collaborative Practice Agreement
[enter collaborating physician’s name]
[enter collaborating pharmacist’s name]
Effective [enter effective date]
I.
Collaborating Parties
Authorized Pharmacist
Name
License #
Practice Location
Email Address
Work Phone #
Cell Phone #
Fax #
Collaborating Physician
Name
License #
Practice Location(s) List each clinic site if
indicated.
Email Address
Work Phone #
Cell Phone #
Fax #
This collaborative practice agreement between [enter collaborating physician’s name] and [enter collaborating
pharmacist’s name] is to provide services to specified patients of [enter collaborating pharmacist’s name]. [Enter
collaborating pharmacist’s name] will assess and manage patients’ falls risk by performing a medication review
for falls risk prevention, a falls risk assessment, a household safety inspection, and preparing a falls prevention
medication action plan.
II.
Scope of Practice
In order for services to take place, a prescription order must be written by [enter collaborating physician’s name]
authorizing the pharmacist to provide medication therapy services (MTS). The authorized pharmacist will be
permitted to manage each patient using a falls risk assessment and adjust medications accordingly by
performing the following standards of care (see below). Duties authorized by [enter collaborating physician’s
Collaborative Practice Agreement
[enter collaborating physician’s name]
[enter collaborating pharmacist’s name]
Effective [enter effective date]
name] are not to be delegated to anyone other than [enter collaborating pharmacist’s name]. For patient care out
of the scope of practice of [enter collaborating pharmacist’s name], not included in this agreement, the patient will
be referred back to [enter collaborating physician’s name] for further evaluation. [Enter collaborating pharmacist’s
name] shall not be authorized to adjust, change, or modify any controlled substance prescribed to a patient.
Any changes to a controlled substance will be referred back to [enter collaborating physician’s name].
Consultations will be made through [enter collaborating physician’s name] only, unless emergency services are
needed. American Geriatrics Society guidelines (AGS) will be used as a guide to support the decisions made
for patient care.
Authorized abilities
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Initiate, modify or discontinue
medications in accordance with
respective clinical guidelines
Request access to patient records for
MTS purposes at collaborating
physician’s office
Perform falls risk assessment
Perform household safety inspections
Order and evaluate laboratory tests
Obtain and check vital signs
Collect and review patient histories
Prepare a medication review followed
by a Medication Action Plan
Educate and counsel patients on plan
of care
Provide follow up care (i.e. evaluating
labs, side effects, and treatment
progress) if necessary
Document clinical outcomes
Other:
Authorized
medications/classes
 ACE-Inhibitors
 Alcohol
 Alpha Receptor Blockers
 Anti-coagulants
 Anti-convulsants
 Anti-depressants
 Anti-histamines
 Anti-psychotics
 Corticosteroids
 Digoxin
 Diuretics
 Muscle Relaxants
 Nitrates
 NSAIDS
 Opiates
 Benzodiazepines
 Other:
Authorized laboratory
tests & assessments
 Blood pressure
 Pulse
 CMP
 Liver function tests
 Serum Creatinine
 BUN
 Vitamin D
 Other:
Guidelines
followed
AGS
Collaborative Practice Agreement
[enter collaborating physician’s name]
[enter collaborating pharmacist’s name]
Effective [enter effective date]
III.
Prescription Orders
In order for the authorized pharmacist to provide MTS, a prescription order must be received from the
collaborating physician. The prescription, in either oral, electronic, or paper form, must contain the following
information [20 CSR 2220-6.080(2)(A)]:
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Patient name, address, and date of birth
Date the prescription order was issued
Clinical indication for MT services (i.e. diagnosis)
Authorizing physician’s name and address
Length of time for providing MTS, if less than 1 year
The authorizing physician shall review the pharmacist’s medication therapy service activities regularly, but not
less than once every three (3) months [20 CSR 2220-6.080(3)(D)].
IV.
Documentation of MTS
All authorized pharmacist-patient interactions will be documented in a SOAP-note format and will include:
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Patient’s name, DOB, address, and telephone number
Date and reason for service/consultation
Services performed (e.g. labs, physical exams)
Assessments
Description of medications/therapy modified (strength, dose, schedule, route)
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Referrals made to by [enter collaborating physician’s name] or emergency care
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Contact with by [enter collaborating physician’s name] concerning the patient’s care
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Informed consent procedures
Copies of the SOAP-note will be retained in respective patient files at at [enter name of location where copies of the
pharmacist’s patient records are stored] which are to be protected in locked filing cabinets within the office or in a
HIPAA-compliant, electronic filing system. At any time, the physician will have access to the patient’s
medical records at [enter name of location where copies of the pharmacist’s patient records are stored]. Copies of the
SOAP-note will be faxed to by [enter collaborating physician’s name] office within 3 business days to be filed.
However, if. [Enter collaborating pharmacist’s name] requests to change therapy, the documents will be faxed to
Collaborative Practice Agreement
[enter collaborating physician’s name]
[enter collaborating pharmacist’s name]
Effective [enter effective date]
[enter collaborating physician’s name] office within 24 hours. The physician will review the pharmacist’s
assessments and acknowledge they are in agreement by signing and returning the acknowledgement form at
the end of the SOAP-note. If the authorized physician disagrees with any changes made, the collaborating
pharmacist will be notified by the physician within 3 business days after receiving the document.
V.
Notifications
The following notifications are required under 20 CSR 2220-6.080(5). Notifications will be communicated
within 24 hours for by [enter collaborating physician’s name] review.
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VI.
Anaphylactic or adverse medication reactions
Exposure to body fluids
Needle sticks
Therapy modifications
Quality Improvement
[Enter collaborating physician’s name] and [Enter collaborating pharmacist’s name] will meet for quality improvement
annually or as needed throughout the year. During the first year, the agreement will be evaluated on day 90,
180, and 365. Communications will remain open via email, phone, and face-to-face interaction. Falls history
will be used as baseline data. The number of falls will be compared yearly to baseline data; improvements in
data will reinforce the addition of [Enter collaborating pharmacist’s name]. Improvements will also ensure
patients are receiving quality care.
VII. Retention of records
Records must be maintained for the following timeframes:
Patient records
Written, signed protocols
Prescription MTS orders
7 years after termination of protocol
8 years after termination of protocol
7 years after termination of protocol
Collaborative Practice Agreement
[enter collaborating physician’s name]
[enter collaborating pharmacist’s name]
Effective [enter effective date]
Electronic or paper records will be maintained and stored at the offices of Drs. [enter last name of both physician
and pharmacist].
VIII. Pharmacy Practice Residents
The pharmacy resident may assist and perform MTS under the supervision of their preceptor, [Enter
collaborating pharmacist’s name]. Residents must have an MTS certificate from the MO Board of pharmacy. All
duties allowed will follow aforementioned practices within this agreement.
IX.
Amendments
Changes to the protocol may be amended at any time. However, both parties must agree and sign the
amended document. Dates of each amendment will be recorded. Annual review of the protocol is required
and will be signed by each party on the given date.
X.
Authorization
This agreement will commence on the ________ day of _________ , 2014. It is to be understood that both
parties will maintain unrestricted licensure throughout the duration of this contract, and abide by the laws set
forth in their scope of practice and this agreement.
_________________________________________________________
Authorized Pharmacist
_________________________________________________________
Collaborating Physician
___________________
Date
___________________
Date