Nurse Practitioner
Written Collaborative Agreement
Nurse Practitioner Written Collaborative Agreement
Nurse practitioner name:
Illinois RN license number:
Illinois Advanced Practice license number:
DEA
NPI
Area of certification:
Women’s Health
Certifying organization:
National Certification Corporation
Certification expiration date:
Certification number:
N/A
Practice site name and address:
Contact number:
Facsimile number:
Emergency contact number:
Collaborating physician name:
Illinois license number:
Board certification specialty:
Certifying organization:
Contact number:
Facsimile number:
Emergency contact number:
Ob-Gyn
Definitions of Terms
"Act" means the Nursing and Advanced Practice Nursing Act.
"Advanced Practice Nurse "APN" or "Certified Nurse Practitioner (CNP)" means a person
who:
- is licensed as a registered professional nurse under the Act;
- meets the requirements for licensure as an advanced practice nurse under Section
15-10 of the Act:
- except as provided in Section 15-25 of the Act, has a written collaborative
agreement with a collaborating physician in the diagnosis of illness and management of
wellness and other conditions as appropriate to the level and area of his or her practice in
accordance with Section 15-15 of the Act; and cares for patients:
- by using advanced diagnostic skill, the results of diagnostic tests and procedures
ordered by the advanced practice nurse, a physician assistant, a dentist, a podiatrist, or a
physician, and professional judgment to initiate and coordinate the care of patients;
- by ordering diagnostic tests, prescribing medications and drugs in accordance with
Section 15-20 of the Act, and administering medications and drugs; and
- by using medical, therapeutic, and corrective measures to treat illness and improve
health status.
"Collaborating Physician" means a physician who works with an advanced practice nurse and
provides medical direction as documented in a written collaborative agreement required
under Section 15-5 of the Act.
"Physician" means a person licensed to practice medicine in all its branches under the
Medical Practice Act of 1987. (Section 15-5 of the Act).
Guidelines of Collaboration
Scope of Practice
The nurse practitioner and physician whose signatures appear below enter into this Written
Collaborative Agreement as required by the Illinois Nursing and Advanced Practice Nursing
Act. They agree to abide by all state and federal regulations governing the practice of
advanced practice nursing.
Under this agreement, the advanced practice nurse will work with the collaborating physician
in an active practice to deliver health care services to pregnant and non-pregnant women in
the OB/GYN setting. This includes, but is not limited to, diagnosis, treatment and
management of acute and chronic health problems; ordering, interpreting, and performing
laboratory and radiology tests; prescribing medications to the extent delegated; receiving and
dispensing stock and sample medications; performing other therapeutic or corrective
measures as indicated.
This written collaborative agreement shall be reviewed and updated annually. A copy of this
written collaborative agreement shall remain in file at all sites where the Advanced Practice
Nurse renders service and shall be provided to the Illinois Department of Professional
Regulation upon request.
Any joint orders or guidelines are set forth or referenced in Attachment A.
Nurse Practitioner – Physician Relationship
The physician and nurse practitioner shall communicate with each other either in person or
by telecommunications as needed. The physician must be on site at least once a month to
provide medical direction and consultation. In the absence of the designated collaborating
physician, other physicians shall be available for consultation.
The nurse practitioner shall inform each collaborating physician of all written collaborative
agreements she has signed with other physicians, and provide a copy of these to any
collaborating physician upon request.
General Nurse Practitioner Services
1.
2.
3.
4.
5.
Perform comprehensive physical assessments.
Provide services related to health maintenance and promotion.
Establish diagnoses for common short-term and chronic stable health conditions.
Order, interpret, and perform laboratory and radiology tests.
Prescribe medications, limited to legend drugs.
6.
7.
8.
9.
10.
Provide stock and sample medications.
Perform other therapeutic or corrective measures as indicated.
Refer patients to licensed physicians or other health care providers as indicated.
Provide urgent care as indicated.
See Attachment A.
Medical Direction
A physician’s presence is not required when the nurse practitioner renders care in accordance
with the Clinical Practice Guidelines and Nurse Practitioner’s education and experience
unless indicated in the Clinical Practice Guidelines.
The collaborating physician or his delegate will be available in person or by means of
telecommunication when the nurse practitioner renders care for the purpose of consultation
on medical problems, complications, or emergencies, or patient referral in accordance with
the Clinical Practice Guidelines.
The physician delegates the prescriptive authority for legend and legend controlled
substances, Schedules III, IV, and V to the Advanced Practice Nurse.
We the undersigned agree to the terms and conditions of this written collaborative agreement.
__________________________________________________________________
Collaborating Physician
Date
__________________________________________________________________
Advanced Practice Nurse
Date
ATTACHMENT A
CLINICAL PRACTICE GUIDELINES
The following is a list of conditions that Nurse Practitioners are allowed to treat:
Gynecology
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Routine well woman exam
Vaginitis
Breast exam
Family Planning
o Oral contraceptive pills
o Birth control patch
o Depo provera
o Diaphragm
o Vaginal ring
Sexually transmitted diseases
Acute pelvic inflammatory disease
Amenorrhea
o Obtain appropriate laboratory tests
o Treat as appropriate with Provera and OCP's
Urinary tract infections
Dysmenorrhea
Menopause
Perimenopause
Premenstrual Syndrome/PMDD
Infertility
o Initial laboratory work-up
o Semen Analysis
Pessary Cleaning
IUD Removal
Preconceptual Counseling
Emergency Contraception
Dysfunctional Uterine Bleeding
o Endometrial biopsy
Obstetrics
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New obstetrics
Return obstetrics
o Without complications
o Until 32 weeks gestation
o Previous c/section patients transfer to physician by 20 weeks
o Post-partum exams – vaginal birth
All high risk Ob patients transferred to perinatologist care after initial ob visit.
All ob patients with complications transferred to physician care immediately.
Conditions requiring patients to be referred to and or consulted with a physician.
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Dysfunctional uterine bleeding
Post-menopausal bleeding
Pelvic pain
Infertility – after initial blood work performed
Benign/malignant pelvic neoplasms
Pelvic abscess
Symptomatic leiomyomata
PID unresponsive to initial treatment
Vulvar dystrophy
Suspicious vulvar/vaginal/cervical lesions
Osteoporosis
Tubal ligation consultations
Essure consultations