COLLABORATIVE PRACTICE AGREEMENT
For use with Advanced Practice Nurse practicing at
SHALOM HEALTH CARE CENTER, INC.
Shalom Health Care Center, Inc.
Primary Care Clinic
3400 Lafayette Road, Suite 200
Indianapolis IN 46222
Farrington Elementary School Clinic
4326 Patricia Street
Indianapolis IN 46222
Gambold Middle School Clinic
3725 Kiel Avenue, Room105
Indianapolis IN 46224
Northwest High School Clinic
5525 W. 34th Street, Room 179
Indianapolis IN 46224
Advanced Practice Nurse
Complete Name:
Home Address and Telephone:
Work Address and Telephone:
3400 Lafayette Road
Indianapolis, IN 46222
License:
RN License
Expires:
Certification:
Pediatric Nurse Practitioner
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Physician
Complete Name:
Home Address and Telephone:
Work Address and Telephone:
Shalom Health Care Center, Inc.
3400 Lafayette Road, Suite 200
Indianapolis, IN 46222
317-291-7422
License:
Certification:
M.D.
Advanced Nurse Practice Clinics
The Northwest High School Clinic of the Shalom Health Care Center, Inc. is housed in
the Indianapolis Public School Corporation. The clinic manages children in the preadolescent
and adolescent ages ranges. It is anticipated that 200 patients will be seen weekly.
Scope of Practice
This Collaborative Practice Agreement entered into 20th day of June, 2008, by and
between Dr. Dannee J. Neal, physician duly licensed to practice medicine in the state of Indiana
(hereinafter “Physician”), and Beth Pickens, advanced practice nurse, PNP duly licensed to
practice advanced nursing as a pediatric nurse practitioner. The pediatric nurse practitioner and
family physician will work together both independently and together as members of the health
care team.
Beth Pickens will function in the role of pediatric nurse practitioner. This PNP will
adhere to Indiana Board of Nursing Rules and Regulation (LSA Document 94-39) and to the
standards defined in Scope of Practice for Primary Care by the American Nurses Association.
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Dr. Dannee J. Neal will function in the specialty of family medicine. This physician will
adhere to the scope of practice delineated in the Indiana Medical Practice Act. The physician
will be on call to the ANP on the days Shalom Health Care Center, Inc. is open. Any patient
needing a physician evaluation will be referred to Dr. Dannee J. Neal.
The scope of practice of the PNP at Shalom Health Care Center, Inc. will include the
following:
1.
Conduct comprehensive physical assessment.
2.
Establish diagnoses for common short-term acute illness and uncomplicated chronic
illnesses.
3.
Order, perform, and interpret laboratory tests.
4.
Prescribe medications.
5.
Order radiologic procedures.
6.
Refer patients to appropriate physicians and other health care providers at appropriate
agencies.
7.
Provide health maintenance and promotion.
8.
Provide client education.
9.
Institute emergency care.
Insurance
APN, in provision of her duties as a pediatric nurse practitioner shall be acting as an
employee or Shalom Health Care Center, Inc. and as such, Shalom Health Care Center, Inc. shall
provide medical malpractice insurance so as to qualify the APN as a provider under the Indiana
Medical Malpractice Act (I.C. 27-12 et seq.).
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Dr. Dannee J. Neal, MD, shall carry, as an employee of Shalom Health Care Center, Inc.,
medical malpractice insurance with those limits to qualify the providers under the Indiana
Medical Malpractice Act (I.C. 27-12) and the physician agrees to be and remain a qualified
provider thereunder.
Collaborative Responsibilities of Nurse Practitioner and Physician
Nurse Practitioner
1.
Promote patients’ health.
2.
Manage patients’ non-complicated acute and stable chronic conditions. Refer clients as
necessary to Dr. Dannee J. Neal or other designated physicians at other agencies.
3.
Initiate weekly communications with Dr. Dannee J. Neal.
4.
Inform Dr. Dannee J. Neal on a weekly basis about medication use.
5.
Work as part of collaborative clinic team.
Physician
1.
Accept referrals from Shalom Health Care Center, Inc.
2.
Meet with nurse practitioner on a weekly basis.
3.
Manage patients with more complex conditions.
4.
Be available on call during Shalom’s clinic hours by pager or phone. In the event of
vacation or other time off, Dr. Dannee J. Neal will make every attempt to continue to be
available by phone or pager. When this will not be possible, coverage will be arranged in
advance to be provided by another physician licensed in the state of Indiana. The nurse
practitioner will receive notification of this well in advance of the absence, including the
covering physician’s name, credentials and contact information.
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Prescriptive Authority
Beth Pickens, PNP, because of her skill, training and competence, has the authority to
administer, dispense, and prescribe drugs and provide treatment within the scope of practice for a
pediatric nurse practitioner.
Beth Pickens, PNP, is permitted to authorize pharmacists to fill prescriptions, including
telephone prescriptions as defined in the law. Such prescriptions may be forwarded or
transmitted to the pharmacist by the ANP, a registered professional nurse or other authorized
agent.
All services performed pursuant to the Agreement shall be performed in a manner
consistent with rules and regulations governing physician practices and advance nursing
practices in Indiana.
The Agreement shall be applicable with respect to services provided within the scope of
responsibility of a pediatric nurse practitioner and shall not be valid unless and until
acknowledged by Dr. Dannee J. Neal, MD.
Quality Assurance
Reviews will occur with the nurse practitioner and physician to review prescribing and
management practices. The physician will review charts with the nurse practitioner on a weekly
basis. There will be a random sampling on 5% of the charts during that time period for the
physician and nurse practitioner to evaluate prescriptive privileges.
This Agreement can be terminated at any time by either physician or advance nurse
practitioner by written notice to the other. The party terminating such Agreement shall
simultaneously provide a copy of termination to the Executive Director of Shalom Health Care
Center, Inc.
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This Agreement will be reviewed yearly and must be renewed every two years for the
Indiana State Board of Nursing. Any changes with this agreement within those two years must
be submitted to the Indiana State Board of Nursing.
Physician:
Date:
Advanced Nurse Practitioner:
Date:
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