Collaborative Practice Agreement
Medication Management Pharmacist
South Carolina
Collaborative Practice Agreements (CPAs) are used to create formal relationships between
pharmacists and physicians that allow for expanded patient care services the pharmacist can
provide to patients and the healthcare team.
The authority to obtain patient history, collaborate on physical assessments, order and assess
diagnostic tests, make medication related medical decisions, and modify therapy management
options is derived from the delegation of that authority by the South Carolina licensed physicians
signed below who shall supervise the delivery of those delegated medical acts, in accordance
with South Carolina Code 40-47-20 (13) and 40-47-195 and the South Carolina pharmacist scope
of practice.
The South Carolina licensed physician(s) signed below are working in collaboration with
__________________, Medication Management Pharmacist, licensed in South Carolina, and
agree to delegate and supervise delegated medical acts as defined in the attached Scope of
Pharmacy Practice Guidelines and Treatment Protocols.
_____________________________________________
(Name, MD, SC License #)
_____________________________________________
(Name, MD, SC License#)
_____________________________________________
(Name, MD, SC License#)
_____________________________________________
(Accepted by Name, PharmD, SC License#)
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Scope of Practice Guidelines
Purpose/Background
The goal of this agreement is to improve care, achieve optimal outcomes, and provide continuity
of care to patients through the provision of pharmacy patient care services which include therapy
care plan development, medication management, education, monitoring, and follow-up.
To enhance collaborative patient care, pharmacists will be delegated the authority to obtain a
patient medical history, order and evaluate laboratory results, conduct limited examinations, and
make medical decisions including initiating, modifying, or discontinuing treatment when
appropriate with their scope of practice.
This document identifies the specific responsibilities of collaborative partners to provide safe,
effective and timely care to patients.
Organization
Location(s):
(Insert various collaborative practice sites for supervising physicians)
Guidelines for referral: Only the supervising physician(s) can refer patients they feel would
benefit from pharmacy patient care services and the referral will be documented in the patient’s
chart.
Conditions: (For example purposes only-modify for practice)
 Diabetes
 Hypertension
 Congestive Heart Failure
 COPD
 Asthma
 Lipid Disorders
 Anticoagulation Management
 Polypharmacy Management
 Others as identified in attached Treatment Guidelines
Patient Care Services provided by the pharmacist under the supervisor of the physician:
 Obtain patient medical history,
 Order and evaluate laboratory results
 Conduct limited examinations
 Make medical decisions including initiating, modifying, or discontinuing treatment
 Refill authorization
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Documentation: All patient encounters will be documented in the patient record and will be
available to the supervising physician for review.
Quality Improvement
Data will be continuously monitored to ensure that patients are receiving optimal care. Clinical
activities will be reviewed from time to time by the clinical pharmacist and physician providers,
and revised as needed.
Modifications
Any modifications to this agreement must be dated and signed by all collaborative partners.
South Carolina Pharmacist Scope of Practice for Patient Care Services
Following is the opinion issued on March 18, 2015 by the South Carolina Board of Pharmacy
regarding the scope of practice for pharmacist providing patient care services.
The South Carolina Board of Pharmacy confirms that the scope of pharmacy practice as defined
in the South Carolina Pharmacy Practice Act permits a South Carolina licensed pharmacist, in
collaboration with a South Carolina licensed physician, to obtain a patient medical history,
evaluate laboratory results, conduct limited examinations, and make medical decisions pursuant
to a medical order.
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Treatment Guidelines
(For example purposes only-modify for practice)
1. Anticoagulation
 The ACCP Conference on Antithrombotic and Thrombolytic Therapy, CHEST
Supplement
2. Asthma
 National Asthma Education and Prevention Program Expert Panel Report: Guidelines
for the Diagnosis and Management of Asthma
3. Chronic Heart Failure
 ACC/AHA Guideline for the Diagnosis and Management of Chronic Heart Failure in
the Adult
4. Cholesterol
 NCEP: Report of the Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (Adult Treatment Panel III)
5. Diabetes
 American Diabetes Association Clinical Practice Guidelines, Diabetes Care
6. Hypertension
 The Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure
7. Smoking Cessation:
 Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians.
Rockville, MD: U.S. Department of Health and Human Services. Public Health
Service.
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