Nurse Practitioner Protocol
I. General Information
A. Nurse Practitioner:
(name and degree)
Department of xxxxxxx
Medical University of South Carolina
(address)
Charleston, SC 29425
B. Primary Supervising Physician:
(name and degree)
Department of xxxxxx
Medical University of South Carolina
(address)
Charleston, SC 29425
C. Back-up Supervising Physicians
xxxxxxxx, MD, xxxxxxxx, MD, xxxxxxxxxxx, MD, xxxxxxx, MD xxxxxxxxx, MD,
xxxxxxxx, MD xxxxxxxxx, MD.
D. Area of Practice/Specialty/Population/Nature of Practice
(nurse practitioner) will participate in the care of ...
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
E. Practice Location (s)
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
F. Consultation with Supervising Physicians:
The nurse practitioner will maintain open communication with the supervising
physicians in person, by beeper, or by telephone on a daily basis as needed. Orders
communicated to the nurse practitioner will be implemented and documented
appropriately. A supervising physician must be within 45 miles of the clinic setting, in
accord with the regulations of the South Carolina Board of Nursing.
In the event of a life-threatening emergency, the nurse practitioner will institute CPR
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until the arrival of a physician.
II. Delegated Medical Acts
A. Medical conditions for which treatment may be initiated, continued or modified:
This list includes, but is not limited to the following:
Xxxxxxxxx
Xxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxxxx
B. Treatments/Interventions:
Under the general supervision of an attending physician, the nurse practitioner may
initiate, continue and/or modify the following measures based on ongoing assessment,
diagnosis, plan, intervention, and evaluation of patient status:
1. Obtain medical histories and perform physical examinations.
2. Conduct health assessment of patient and families with acute and/or chronic health
problems, including physical, cognitive, and psycho-social.
3. Provide direction for in-hospital patient care via daily rounds.
4. Record subjective and objective data, assessment and plan of care in progress notes.
5. Based on diagnosis/differential will order diagnostic tests and consultations as
needed.
6. Evaluate patient responses to disease processes and therapeutic interventions to
determine the effectiveness of care, and modify accordingly.
7. Collaborate with physicians, NP’s and other health care providers to provide
optimum patient care.
8. Provide patient and family support and education.
9. Develop individualized treatment plans with appropriate discharge and follow-up
care for inpatient and outpatient populations.
10. Provide outpatient support and services during clinic as well as via phone
consultations.
C. Pharmacological Therapy
The following medications may be prescribed, altered, and/or discontinued in accordance
with established protocols:
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1. xxxxxxxxxxxxxxx;
2. xxxxxxxxxxxxxxx;
3. xxxxxxxxxxxxxxxxxxxxxxx;
4. xxxxxxxxxxxxxxxxxxxxxx
5. xxxxxxxxxxxxxxxxxxxxxxxx
6. xxxxxxxxxxxxxxxxxxxxxxxxxx;
7. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx;
8. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx;
9. xxxxxxxxxxxxxxxxxxxxxxxxxx;
10. xxxxxxxxxxxxxxxxxxxxxxxxxxx;
11. xxxxxxxxxxxxxxxxxxxxxxxxx;
12. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx;
13. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx;
14. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx;
15. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx;
16. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx;
17. xxxxxxxxxxxxxxxxxx;
18. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
D. Situations Requiring Physician Referral/Direct Evaluation
Any condition, which exceeds the education and training of, or raises question or
concern by the judgment of the nurse practitioner, shall require referral and direct
evaluation by a physician. These conditions may include, but are not limited to the
following:
1. Failure of the patient to respond to therapies initiated by the nurse practitioner.
2. Deterioration of the patient or circumstances that require more invasive intervention
than can be provided by the nurse practitioner.
3. Conditions unveiled by diagnostic procedures, which are beyond the scope of the
nurse practitioner.
4. Any emergent situation or procedure for which the nurse practitioner has not been
trained or educated.
III. Dates:
a. Date Protocol Developed:
b. Date Reviewed:
c. Date Revised:
IV. Signatures:
Nurse Practitioner
Signature
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Date
Supervising Physician
Signature
Date
Back-up Physician
Signature
Date
Back-up Physician
Signature
Date
Back-up Physician
Signature
Date
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