COLLABORATIVE PRACTICE AGREEMENT
THIS COLLABORATIVE PRACTICE AGREEMENT (“Agreement”) is made and entered into this ____ day of _________, 2008, by and between ______________, hereinafter referred to as “Physician,” and ___________________, hereinafter referred to as “Nurse Practitioner.”
WHEREAS, the Physician is licensed to practice medicine in the State of West Virginia and has been granted clinical privileges by the Medical and Dental Staff of _____________ (“the Hospital”);
WHEREAS, the Nurse Practitioner has completed his/her degree and passed a national certification exam, which entitles him/her to practice as a licensed, certified nurse practitioner;
WHEREAS, the Nurse Practitioner will be employed by the Hospital, and will provide services at one or more of the Hospital’s facilities in collaboration with the Physician; and
WHEREAS, the Physician and the Nurse Practitioner have reached an agreement on the terms and conditions of a collaborative relationship which is reduced to writing in this Agreement.
NOW, THEREFORE, the parties hereby agree as follows:
- This Agreement shall be for an initial term of two (2) years from the date set forth above.Thereafter, this Agreement may be extended for one or more additional terms of two (2) years each upon the agreement of the parties. This Agreement may be terminated by either party upon thirty (30) days prior written notice. In addition, this Agreement shall be automatically terminated upon any of the following occurrences:
- The Physician loses his/her license to practice medicine in the State of West Virginia;
- The Nurse Practitioner loses his/her license as a Registered Nurse in the State of West Virginia or his/her certification for advanced nursing practice;
- Either party’s clinical privileges at the Hospital are withdrawn or restricted in whole or in part pursuant to the procedures set forth in the Medical and Dental Staff Bylaws;
- Either party is sanctioned by or excluded from participation in any federally funded health care programs or is convicted of any felony or is convicted of a misdemeanor involving moral turpitude or otherwise impairs his/her ability to carry out the terms and conditions of this Agreement.
- The Nurse Practitioner is no longer employed by the Hospital.
- The Nurse Practitioner shall perform professional services consistent with the Scope of Practice, attached hereto as Exhibit A and incorporated by reference.Any modifications to that Scope of Practice by the Medical and Dental Staff of the Hospital shall also be incorporated by reference as of the date they are effective.
- The Nurse Practitioner shall order, perform and interpret laboratory and other diagnostic tests, as the same shall relate to patients under the care of the Physician and the Nurse Practitioner.The Nurse Practitioner shall consult with the Physician regarding abnormal findings or test results where appropriate.
- The Nurse Practitioner may prescribe medications to meet the wellness and illness needs of the patient, based on the patient’s history and physical examination.The Nurse Practitioner shall only prescribe medications for which he/she has been approved by the Physician, and has received prescribing rights. A list of such medications is attached hereto as Exhibit B and incorporated by reference. Any modifications to the list of medications shall also be incorporated by reference as of the effective date of such list. All prescriptive authority shall be consistent with applicable West Virginia law, the legislative regulations promulgated by the West Virginia Board of Examiners for Registered Nurses and the legislative regulations related to controlled substances, including, but not limited to, The Uniform Controlled Substances Act.
- All prescriptions shall include the following information:
- Name and address of the patient
- Date of prescription
- Full name of drug, dosage, route of administration and directions for use
- Number of refills
- Name, title, address and phone number of prescriber
- Expiration date of prescriptive authority
- Signature of prescriber on the written prescription
All prescriptions shall be documented in the patient’s record.
- The Nurse Practitioner shall refer patients to appropriate physicians and consultants outside the Hospital consistent with the specific needs of the patients and based on indications for consultation.
- The Physician shall make himself/herself available for consultation with the Nurse Practitioner in person or by telephone relative to the medical management of patients under her care.
- The Physician shall take over the medical management of unstable patients or shall designate an alternate physician to take over the management of such patients.
- The Physician shall conduct a quarterly review and evaluation of the Nurse Practitioner’s care and prescribing practices.The number and variety of cases to be evaluated shall be determined by the Physician, but shall not be less than fifteen (15) for each quarter and shall include a representative sample of cases involving the Nurse Practitioner’s exercise of prescriptive authority.
- The Physician shall initially review and approve all guidelines and protocols applicable to the Nurse Practitioner’s performance of professional services.All approved guidelines and protocols shall be reduced to writing and maintained by the Nurse Practitioner. The Physician also shall conduct an annual review of such guidelines and protocols and provide the Nurse Practitioner with written updates as new information becomes available regarding treatment guidelines and protocols. The Nurse Practitioner shall participate in all reviews and updates of such guidelines and protocols.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the day and date first set forth above.
Nurse Practitioner _____________________
Exhibit A – Scope of Practice
Exhibit B – List of Medications