Sample Nurse Practitioner/Doctor Protocol

ARNP Protocol
Requiring Authority:
A.Nurse Practice Act, Florida Statutes, Chapter 464
B.Florida Administrative Code, Rules Chapter 64B9-4 Administrative Policies Pertaining to Advanced Registered Nurse Practitioners

Parties to Protocol:
Your name, license number and Practice address
The doctor’s name, license number and practice address
Nature of Practice:
This collaborative agreement is to establish and maintain a practice model in which the nurse practitioner will provide health care services under the general supervision of Dr. XXX. This practice shall encompass family practice and shall focus on health screening and supervision, wellness and health education and counseling, and the treatment of common health problems.
Description of the duties and management areas for which the ARNP is responsible:

A. Duties of the ARNP:
The ARNP may interview clients, obtain and record health histories, perform physical and development assessments, order appropriate diagnostic tests, diagnose health problems, manage the health care of those clients for which she has been educated, provide health teaching and counseling, initiate referrals, and maintain health records.

B.The conditions for which the ARNP may initiate treatment include, but are not limited to:
Otitis media and externa, Conjunctivitis, URI, UTI, Sinusitis,
COPD, Asthma, Bronchitis, Diabetes Mellitus, CHF, HTN

C.Treatments that may be initiated by the ARNP, depending on the patient condition and judgment of the ARNP:
1.Mole removal
2.Incision and Drainage of abscesses.

Duties of the Physician:
The physician shall provide general supervision for routine health care and management of common health problems, and provide consultation and/or accept referrals for complex health problems. The physician shall be available by telephone or by other communication device when not physically available on the premises.

Specific Conditions and Requirements for Direct Evaluation:
The ARNP will maintain open and regular communication with Dr. XXX regarding the practice and patients and consult with Dr. XXX for conditions falling outside the scope of her ability to manage.

All parties to this agreement share equally in the responsibility for reviewing treatment protocols as needed and no less than annually. Practicing ARNPs must file a protocol at the time of renewal or when there are changes with the Board of Nursing. Alterations or amendments should be signed by all parties and filed with the Board within 30 days. Each party should keep a copy for each review period for a period of four years. The supervising physician is responsible for submitting a notice to the Board of Medicine that they have entered into a supervisory relationship with an ARNP.
____________________________/ ________________ License # ARNP
XXXXX, ARNP-BC


____________________________/____________ License #ME___________________
Dr. XXX, MD DEA # ________________________