Fairview Health Services NURSE PRACTITIONER Delineation of Privileges CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES

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1 Fairview Health Services NURSE PRACTITIONER Delineation of PAGE 1 OF 12 Applicant s Name (please print): CROSSWALK F REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview Entity I need to the following Fairview Entity Box on Privilege Form Inpatient/hospital(s) Individual Fairview hospital(s) Fairview Maple Grove Medical Center ( Care Center) 1, 2 University of Minnesota Medical Center, Fairview (UMMC) Fairview Maple Grove Surgery Center 1 Fairview Maple Grove Surgery Center (MGASC) Fairview Hospital-Based Clinic (such as UMMC Clinics, Fairview Ridges Specialty Clinic for Individual Fairview hospital where clinic is affiliated Children, Fairview Southdale Oncology Clinic, Fairview Southdale Hospital Breast Center) 1, 3 Fairview Free-Standing Clinics 1 Fairview Group Practice Clinics (FV Clinics) 1 privileges to practice at Fairview hospital-based clinics and other non-hospital-based Fairview owned entities are only available to those practitioners authorized by Fairview to practice at those sites. privileges do not include performance of procedures which are not otherwise available or performed at the individual ambulatory sites as determined by the operational manager or other appropriate personnel. 2 granted by UMMC can also be exercised at the Maple Grove Care Center in accordance with procedures available at this site. 3 granted by the specific hospital entity can also be exercised at hospital-based clinics affiliated with that entity in accordance with procedures available at the clinic. Degree Education Licensure Board Certification Sponsorship Sponsoring Physician Collaborative Agreement General Supervision Direct Supervision Personal Supervision RN THRESHOLD CRITERIA Completed a masters degree in nursing or post graduate program in nursing specific to the area of advanced practice nursing Meet the education requirements for certification by a national nurse certification organization acceptable to the Minnesota Board of Nursing for advanced practice nursing Must hold current Minnesota RN license Must be Board Certified by a national nurse certification organization acceptable to the Minnesota Board of Nursing and specific to the area in which you wish to practice (see listed in individual privilege sections) Must be within 6 months after completion of an advanced practice nursing course of study and in the process of meeting the requirements for certification. If you fail the certification examination, you must stop practicing as an advanced practice registered nurse (per MN Board of Nursing). Nurse practitioners practicing in a Fairview entity are sponsored staff and required to have a physician sponsor who is in good standing on staff at the Fairview entity to which the applicant is applying. Sponsoring/supervising physician must hold privileges for the procedures you are requesting at the hospital to which you are applying. The applicant must have a signed Fairview Nurse Practitioner/Physician Collaborative Practice Agreement with a physician in good standing on the staff at the Fairview entity to which the applicant is applying and have prescriptive authority through the Minnesota Board of Nursing. The Collaborative Agreement is attached. SUPERVISION LEVELS The care, activity or procedure is provided or performed under the physician s oversight and overall direction and control, but the physician s presence is not required while it is being provided or performed. The physician accepts responsibility and liability for the quality of care provided by the person being supervised. privileges are performed under General Supervision unless otherwise stated. The physician is present in the area and immediately available to furnish assistance and direction throughout the time the care, activity or procedure is provided or performed. It does not mean the physician must be present in the room while the procedure is performed. The physician accepts responsibility and liability for the quality of care provided by the person being supervised. The physician must be in attendance in the room while the care, activity or procedure is provided or performed. The physician accepts responsibility and liability for the quality of care provided by the person being supervised. Q:\Central Metro-Shares\UMMC Business\Share Dir\Credentialing Dept\Privilege Forms\Nurse Practitioner.doc Revised: 10/01; 6/02; 12/02; 1/04; 1/05 (subcomm); 3/06; 8/06 (subcomm); 1/07 (subcomm); 6/07 (subcomm); 9/07; 3/08; 5/08; 7/8/08 (subcomm); 9/08; 6/09 (new format); 9/14/09; 12/09; 2/10; 6/11; 7/11; 8/11; 12/11;1/12;8/12;9/12;5/13;7/13;8/13;3/14;4/14;6/14

2 Fairview Hospital Entity Codes UMMC - University of Minnesota Medical Center, Fairview FSH - Fairview Southdale Hospital FRH - Fairview Ridges Hospital FNH - Fairview Northland Medical Center FLH - Fairview Lakes Medical Center Fairview Entity Code FV Clinics = Fairview Free-standing Clinics MGASC = Fairview Maple Grove Surgery Center PAGE 2 OF 12 Definitions/Abbreviations - routinely taught in training programs Special Request - not routinely taught in training programs; new technology or procedure; high risk; or requires ongoing practice to maintain competency N/A - Indicates privilege not available at the specific Fairview entity AF - Indicates an additional form is required to request the privilege ADULT/GERONTOLOGY NURSE PRACTITIONER Must meet all listed on page 1 Current Nurse Practitioner certification in the area of Acute, Adult, Family Medicine, Women s Health or Gerontology Check Entity(ies) Where Requested include providing general health care and treatment of adult patients including examination of patients, performance of health histories and physical exams, ordering, interpreting and evaluating diagnostic tests and recording findings. also include: Performing minor surgical procedures such as punch biopsy, sebaceous cyst and ingrown toenail removal and repair of minor lacerations with no nerve, tendon or major vessel involvement Management of non-displaced fractures and sprains including casting, insertion and removal of drains May assist sponsoring physician in surgery or with other treatment procedures Care of indwelling vascular catheters, chest tubes, gastrostomy tubes, gastrojejunostomy tubes, cecostomy tubes sclerotherapy tubes, and abscess drainage tubes Order restraints per Fairview policy privileges do not include prescribing privileges (see Prescriptive ) MAPLE GROVE AMBULATY SURGERY CENTER Must meet all listed on page 1 Current Nurse Practitioner certification in the area of Acute, Adult, Family Medicine, Women s Health or Gerontology include ability to evaluate, diagnose, and provide pre-, intra- and postoperative care, treatment, and services consistent with surgical practice, including the performance of physical exams, diagnosing conditions, the development of treatment plans, health counseling, prescribing medications, and assisting in surgery for patients within the age group of patients seen by the collaborating/supervising physician. Writing appropriate pre and post operative orders. See Special Requests (page 9). Collaborative Agreement (attached). Check Entity(ies) Where Requested Maple Grove Surgery Center box for MGASC

3 PEDIATRIC NURSE PRACTITIONER PAGE 3 OF 12 Must meet all listed on page 1 Current Nurse Practitioner certification in the area of Pediatrics or Family Medicine Check Entity(ies) Where Requested include providing general health care, treatment and management of common pediatric illnesses of patients from infancy through young adult. include Examination of patients, performance of health histories and physicals based on age and history, ordering, interpreting and evaluating diagnostic tests and recording findings, developmental assessments. also include: Performing minor surgical procedures such as punch biopsy, sebaceous cyst removal and repair of minor lacerations with no nerve, tendon, or major vessel involvement Management of non-displaced fractures and sprains including casting, insertion and removal of drains May assist sponsoring physician in surgery or with other treatment procedures Care of indwelling vascular catheters, chest tubes, gastrostomy tubes, gastrojejunostomy tubes, cecostomy tubes sclerotherapy tubes, and abscess drainage tubes Order restraints per Fairview policy privileges do not include prescribing privileges (see Prescriptive ) NEONATAL NURSE PRACTITIONER Must meet all listed on page 1 Current Nurse Practitioner certification in the area of Neonatal Must be an employee of or hold a contract with Fairview Health System include provision of general health care and treatment of neonatal patients in the NICU or Level II Nursery. include: PIV Venipuncture PICC insertion and removal Radial, brachial arterial stick UAC and UVC insertion/removal Endotrachial intubation Chest tube insertion/removal Needle aspiration Suprapubic bladder tap Lumbar puncture Thoracentesis Paracentesis Check Entity(ies) Where Requested N/A N/A N/A Pericardiocentesis Management of mechanically ventilated patients Percutaneous arterial line placement/removal May also attend high risk deliveries and transport critically ill neonates Care of indwelling vascular catheters, chest tubes, gastrostomy tubes, gastrojejunostomy tubes, cecostomy tubes sclerotherapy tubes, and abscess drainage tubes privileges do not include prescribing privileges (see Prescriptive )

4 PSYCHIATRY NURSE PRACTITIONER PAGE 4 OF 12 Must meet all listed on page 1 Current Nurse Practitioner certification in the area of Mental Health Check Entity(ies) Where Requested include: Conducts comprehensive psychiatric assessments including but not limited to psychosocial history, mental status examination, medical/neurological history, physical findings and laboratory tests within protocol guidelines and within context of N/A N/A N/A N/A N/A collaborative management Perform individual, couple, group and family psychotherapy and/or education Initiate admitting starting orders within context of collaborative management Participate in the administration of psychometric testing and other investigatory tests as is appropriate Perform face to face assessments for restraint and seclusion Initiate and discontinue 72 hour holds Discharge patients Order restraints per Fairview policy privileges do not include prescribing privileges (see Prescriptive ) EMERGENCY SERVICES NURSE PRACTITIONER Must meet all listed on page 1 Current Nurse Practitioner certification Must be employed by or under contract with an entity whose employees or agents are otherwise able to provide professional emergency services within the applicable Fairview hospital s Emergency Department Sponsoring/supervising physician must be an emergency medicine physician who is employed by or under contract with the applicable Fairview hospital s Emergency Department Check Entity(ies) Where Requested include, but are not limited to, assessment of the *patient s medical, physical and psychiatric status, including patient histories, physical exams. also include: Assisting with and/or practicing interventions/procedures as delegated by the N/A N/A collaborating physician or designated alternate Ordering diagnostic tests, activities, therapies, diet and vital signs, IV fluids, blood and blood products, oxygen Recording diagnostic impressions, interpreting and evaluating patient data Instruct, educate, and counsel patients on health status, test results, disease process, and planning, creating and maintaining appropriate patient records Consultation with medical staff members Assess all patients in order to determine if more definitive services are necessary Procedures such as suture removal, wound checks, needlesticks, Rabies shots Treatment of minor lacerations, simple puncture wounds (no neck or abdominal), rashes (not petechial), abrasions, contusions, tooth and/or earache, sunburn, conjunctivitis, cough, foreign bodies to ear/nose/extremities, neck pain, back pain, URI, UTI Treatment of sprains, strains, simple fractures (suspected at triage, no deformity noted) of digits, hand, wrist, toe, foot, ankle, and knee Order restraints per Fairview policy privileges do not include prescribing privileges (see Prescriptive ) Within the scope of these privileges, it is intended that the nurse practitioner be a qualified medical person for purposes of performing medical screening examinations under the Emergency Medical Treatment and Active Labor Act. 42 USC 1395dd.

5 PAGE 5 OF 12 Additional Requirements for Cardiac Cath Lab CARDIAC CATH LAB NURSE PRACTITIONER Must meet all listed on page 1 Current Nurse Practitioner certification Must meet Additional Requirements for Cardiac Cath Lab listed below Initial Appointment: 1) Must document training completed within past 24 months specific to all procedures within the core document assistance with a minimum of 100 cardiac cath lab cases within the past 24 months 2) Must document completion of Radiation Safety Training within past 24 months 3) Must document current Basic and Pediatric Advanced Life Support 4) Must be employed by or under contract with the University of Minnesota Physicians or Fairview Health Services to provide services in the Cardiac Cath Lab at the University of Minnesota Medical Center, Fairview Reappointment: 1) Must document assistance with a minimum of 100 cardiac cath lab cases within the past 24 months 2) Must document current Basic and Pediatric Advanced Life Support 3) Must be employed by or under contract with the University of Minnesota Physicians or Fairview Health Services to provide services in the Cardiac Cath Lab at the University of Minnesota Medical Center, Fairview Check Entity(ies) Where Requested include participating in an ASSISTANT ROLE with patients of any age under the identified supervision level of a cardiologist with appropriate privileges and includes (supervision levels are defined on page 1): General Supervision Performs health history, physical examination, and ongoing assessment of patients with congenital or N/A N/A N/A N/A N/A acquired heart disease or dysrhythmia Perform patient/family teaching for CHD lesions, cardiac catheterization, and all planned interventional therapy Differentiates between normal findings and those that require treatment, consultation, and/or referral Obtain informed consent for cardiac catheterization, administration of blood products and transcatheter interventions Provides interpretation of laboratory studies, ECG, and echocardiographic interpretation Discharges patient Direct Supervision Obtain central venous and arterial access with sheath placement Operate fluoroscopy equipment Camera angulation appropriate for planned angiograms Right and left heart catheterization with hemodynamic monitoring Insert, manipulate and maneuver catheters and guidewires Diagnose and treat patients with congenital or acquired heart disease, abnormal heart rhythms in conjunction with the Interventional Cardiologist. Maintains appropriate anticoagulation Removes pericardial drains Personal Supervision Assist with Diagnostic Angiography First Assist in Interventional Therapeutics Insert, manipulate and maneuver catheters and guidewires Deliver injectable coils Inflate/deflate angioplasty balloons Deliver, deploy, release of devices privileges do not include prescribing privileges (see Prescriptive )

6 PAGE 6 OF 12 Additional Requirements for Advanced First Assist ADVANCED FIRST ASSIST NURSE PRACTITIONER Must meet all listed on page 1 Current Nurse Practitioner certification Must meet Additional Requirements for Advanced First Assist listed below Initial Appointment: 1) Must document successful completion of an accredited RN First Assist training program completed within the past 24 months document working as a First Assist with a minimum of 80 cases within the past 24 months provide documentation from sponsoring physician detailing First Assist training 2) Must document training specific to all the procedures listed under the core 3) Must be employed by or under contract with the University of Minnesota Physicians or Fairview Health Services to provide services in the Operating Room at the University of Minnesota Medical Center, Fairview Reappointment: 1) Must document working as a First Assist with a minimum of 80 cases within the past 24 months 2) Must be employed by or under contract with the University of Minnesota Physicians or Fairview Health Services to provide services in the Operating Room at the University of Minnesota Medical Center, Fairview Check Entity(ies) Where Requested include participating in an ASSISTANT ROLE with patients of any age under the identified supervision level of a surgeon with appropriate privileges and includes (supervision levels are defined on page 1): General Supervision Remove chest tubes N/A N/A N/A N/A Insert chest tubes Remove temporary epicardial pacing wires Removal of transthoracic intercardiac catheters Direct Supervision Make incision Superficial dissection Placement of epicardial pacemaker wires Providing hemostasis with topical preparations Insert central venous and arterial lines Place pericardial membrane Personal Supervision Assist with deep dissection Assist with thoracotomy Placement of direct RA/PA lines Obtaining direct blood samples from PA Adjusting bands and snares Cannulating and decannulating Tying down cannulation suture Saphenous vein harvesting May perform emergent re-entry for tamponade/clotted shunt privileges do not include prescribing privileges (see Prescriptive )

7 PAGE 7 OF 12 INTERVENTIONAL RADIOLOGY NURSE PRACTITIONER Must meet all listed on page 1 Current Nurse Practitioner certification Must be employed by or under contract with a physician group that is able to practice interventional radiology at the University of Minnesota Medical Center, Fairview Check Entity(ies) Where Requested include assisting supervising/collaborating physician with procedures. also include: Performance of health histories and physical exams Consultation and treatment of patients admitted for interventional radiology procedures Initiating requests for commonly performed N/A N/A N/A laboratory studies Performance of venipunctures, intubation of gastrointestinal tract and bladder Performance of electrocardiograms Incision and drainage of superficial abscesses First assist in selected interventional procedures and providing education to patients Care of indwelling vascular catheters, chest tubes, gastrostomy tubes, gastrojejunostomy tubes, cecostomy tubes sclerotherapy tubes, and abscess drainage tubes privileges do not include prescribing privileges (see Prescriptive ) TRANSITIONAL SERVICES NURSE PRACTITIONER Must meet all listed on page 1 Current Nurse Practitioner certification Check Entity(ies) Where Requested Working in collaboration with a physician, providing general health care and treatment of patients, including performing physical exams, assessing patient s clinical problems, and recommending medication or other forms of treatment. Duties and responsibilities include: Examine patients; order, interpret, and evaluate N/A N/A N/A N/A N/A diagnostic tests; record physical findings; formulate treatment plans and prognoses as indicated by the sponsoring physician Perform health history and physical exams Assess and treat common illnesses as indicated by the sponsoring physician Assess and manage common chronic conditions such as diabetes mellitus or high blood pressure as indicated by the sponsoring physician privileges do not include prescribing privileges (see Prescriptive )

8 PAGE 8 OF 12 RETAIL CLINIC NURSE PRACTITIONER Must meet all listed on page 1 Must be employed by or under contract with Fairview Collaborating physician must be a member in good standing on the medical staff at the Fairview entity to which the applicant is applying Check Entity(ies) Where Requested Screen, diagnose and treat common illnesses and injuries of individuals over 18 months of age including: Minor Illnesses - strep throat, ear infection, influenza, sinus infection, conjunctivitus, cough or bronchitis, allergies, mono, bladder infection, Lyme Disease Minor Injuries - minor burn, bruise, back pain, insect bite N/A N/A N/A N/A N/A or sting, stitch removal, sound check, shingles, eczema Skin Treatments - rash, athlete s foot, skin infection, impetigo, ringworm, poison ivy or oak Other treatments include school vaccines including hepatitis B, MMR, menomune, TB, flu vaccine, pregnancy test, blood pressure check, camp/sport physical. privileges do not include prescribing privileges (see Prescriptive ) PRESCRIPTIVE CE Must meet all listed on page 1 Current Nurse Practitioner certification Completion of the Drugs & Devices (#2) section under A Description of Practitioner s Practice of the Fairview Collaborative Agreement (attached) Includes prescribing, administering and dispensing drugs and medical devices as delegated within the Memorandum of Understanding with an appropriate physician - complete Additional Form attached (AF). *NOTE: You may not enter into a prescribing agreement until you are certified as an APRN (per MN Board of Nursing). Check Entity(ies) Where Requested MGASC AF* AF* AF* AF* AF* AF* AF*

9 SPECIAL REQUEST PRIVILEGES may be requested if they are not included in selected core and documentation requirements are met. PAGE 9 OF 12 Sponsoring/supervising physician must hold privileges for the requested procedure at the hospital to which you are applying. If submitting case list as documentation Case list must include date the procedure was performed, type of procedure and where performed (e.g., name of hospital or other facility. Please delete all patient identifiers such as name or medical record number from documentation to protect individual patient confidentiality. LEVEL 1 SPECIAL REQUEST PRIVILEGES Documentation Requirements Required Supervision Level Must provide one (1) of the following - training or cases must have been completed within the past 24 months (unless other requirements are listed): Letter from a training program verifying training specific to the procedure Letter or certificate from an additional training course specific to the procedure or collaborating/sponsoring physician indicating training specific to the procedure has successfully been completed Documentation of performance of specified number of cases for each procedure as listed in Competency Measures/Required # of Cases in Past 24 Months (copies of operative reports, chart notes, or a list of cases performed) General Supervision - Unless otherwise noted, all Level 1 special request privileges are done under General Supervision (see page 1 for definition of supervision levels) LEVEL 1 SPECIAL REQUEST PRIVILEGES If approved, privileges may be performed on patients appropriate to granted core privileges Competency Check Entity(ies) Where Requested Measures/ Required # Cases in Past 24 Months MGASC Bone marrow biopsy/aspiration 5 N/A N/A Lumbar puncture 5 N/A N/A N/A Myelogram 5 N/A N/A N/A Suprapubic bladder tap 5 N/A N/A Sclerotherapy 25 N/A N/A N/A N/A N/A N/A Skin biopsy 5 N/A N/A Lap banding (adjust only) 5 N/A N/A N/A N/A N/A Hysterosalpingogram 5 N/A N/A N/A N/A N/A N/A Paracentesis 5 N/A N/A N/A N/A N/A N/A Thoracentesis 5 N/A N/A N/A N/A N/A N/A Ventilator Management (included in NNP core) Initial Appointment or First Request: Must document training specific to the procedure. Documentation may be in the form of a letter from the training organization or a sponsoring physician who has privileges for the procedure at Fairview Completion of at least 10 ventilator management cases within the past 24 months Robotic Surgery Instrument Placement through Trochars Initial Appointment or First Request: Documentation of completion of training course specific to the procedure completed within the past 24 months. If completion of the course was longer than 24 months ago documentation must also include documentation from sponsoring physician specifying competency in the procedure. Reappointment: Letter from sponsoring physician specifying competency in the procedure. Initial Appointment/ First Request= See specific Requirements Reappointment = 10 cases See Listed Level I Special Request continued on next page N/A N/A N/A N/A N/A N/A N/A N/A

10 PAGE 10 OF 12 LEVEL 1 SPECIAL REQUEST PRIVILEGES If approved, privileges may be performed on patients appropriate to granted core privileges Deep Brain Stimulator Programming Initial Appointment or First Request: Must document involvement in minimum of a 4 month training program with a physician who has privileges for procedure at Fairview where at least 12 deep brain stimulation programming procedures must be done by applicant while being supervised by staff already credentialed for programming. If training program has not been completed yet, must request provisional privileges for proctoring prior to beginning training program at Fairview. Training program sponsored by Medtronic must be completed during the 4 months training program All training must be completed under Personal Supervision Submit documentation to Credentials Committee after completion training for consideration for full privileges under Direct Supervision Clinical Bone Densitometry - You may also obtain referenced additional privilege form (AF) at Competency Check Entity(ies) Where Requested Measures/ Required # Cases in Past 24 Months MGASC Initial Appointment/ First Request = See specific requirements Reappointment = 20 cases N/A N/A N/A N/A N/A AF AF AF AF AF AF AF N/A

11 PAGE 11 OF 12 Documentation Requirements Required Supervision Level LEVEL 2 SPECIAL REQUEST PRIVILEGES Must provide one (1) of the following - training or cases must have been completed within the past 24 months (unless other requirements are listed): Letter from a training program verifying training specific to the procedure Letter or certificate from an additional training course specific to the procedure or collaborating/sponsoring physician indicating training specific to the procedure has successfully been completed Documentation of performance of specified number of cases for each procedure as listed in Competency Measures/Required # of Cases in Past 24 Months (copies of operative reports, chart notes, or a list of cases performed) Direct Supervision - Unless otherwise noted, all Level 2 special request privileges are done under Direct Supervision (see page 1 for definition of supervision levels) LEVEL 2 SPECIAL REQUEST PRIVILEGES If approved, privileges may be performed on patients appropriate to granted core privileges Arterial catheter removal and achievement of hemostasis (included in NNP core) Sinograms and abscess drainage catheters *FSH - injection and care only Competency Check Entity(ies) Where Requested Measures/ Required # Cases in Past 24 Months MGSAC 25 N/A N/A N/A 25 * N/A N/A N/A Chest tube check or removal 25 N/A N/A N/A N/A Enteric Tube Change/Removal 25 N/A N/A N/A Placement of Central Venous Lines, Arterial Lines or PICC Lines *FSH - ultrasound-guided internal jugular placement of central venous line only Imaging Guided Procedures including: spinal injections, joint injections, aspirations, arthrography, fluid collection/aspiration/drainage procedures*, bone/soft tissue biopsy**, chest tube insertion *FSH - thoracentesis and paracentesis only **FSH - supervicial biopsy or aspiration palpable mass only 25 * N/A N/A N/A N/A 25 * ** N/A N/A N/A

12 LEVEL 3 SPECIAL REQUEST PRIVILEGES Any procedures outside your Scope of Practice or Level 1/Level 2 Special Request should be written in and requested below Fairview reserves the right to determine whether the procedure will be offered or granted Fairview will determine the appropriate supervision level Competency Measures/documentation requirements may be modified depending on the type of procedure being requested Documentation Requirements Required Supervision Level PAGE 12 OF 12 Must provide one (1) of the following - training or cases must have been completed within the past 24 months (unless other requirements are listed): Letter from a training program verifying training specific to the procedure. Letter or certificate from an additional training course specific to the procedure. Letter from collaborating/sponsoring physician indicating training specific to the procedure has successfully been completed. Letter must include details of training provided. If training specific to the procedure was longer than 24 months ago, provide documentation of where training occurred and documentation of cases within the past 24 months. LEVEL 3 SPECIAL REQUEST PRIVILEGES If approved, privileges may be performed on patients appropriate to granted core privileges Letter identifying anticipated number of procedures to be performed in 24 month period. Description of Level 3 Special Request Privilege Must include requested supervision level (General, Personal or Direct) Check Entity(ies) Where Requested Requested Supervision Level (General, Personal or Direct) PRIVILEGE FM SIGNATURE (REQUIRED): I understand that by making these privilege requests, I am bound by the applicable bylaws or policies of the entity to which I am applying. I also attest that I have met the education requirements for prescriptive core (if requested) and that my professional liability insurance covers the scope of practice listed. Signature Date Sponsoring Physician Signature Date

13 PAGE 1 OF 4 COLLABATIVE PRACTICE AGREEMENT NURSE PRACTITIONER-PHYSICIAN Fairview supports the role of Nurse Practitioners and their vital role in delivering high quality care to patients. Fairview supports a process and relationship in which Nurse Practitioners work in expanded roles in collaboration with the physician and other health care providers within the scope of the professional experience of the Nurse Practitioner toward the common goal of providing high quality care to patients. This supports a model where Nurse Practitioners work with the health delivery team to the top of their licensure while providing for the appropriate supervision in the delivery setting for certain types of procedures and/or interventions as set forth in the applicable privilege form. The Memorandum of Understanding between the Minnesota Medical Association and the Minnesota Nurses Association requires that the Collaborative Practice Agreement be reviewed and signed by the parties at least annually and whenever the situation calls for amendment. Each Nurse Practitioner must have a signed practice agreement with at least one physician. In addition, the Nurse Practitioner must follow applicable Fairview system or entity policies or procedures including the Allied Health Staff Credentials Policy. FAIRVIEW ENTITIES (check entities to which you are applying): University of Minnesota Medical Center, Fairview Fairview Lakes Regional Medical Center Fairview Northland Medical Center Fairview Ridges Hospital Fairview Southdale Hospital Fairview Clinics Fairview Maple Grove Surgery Center NURSE PRACTITIONER INFMATION 1. Identification: Name (please print): Practice address(es): Practice telephone number: Home address: Minnesota Registered Nurse license/identification number: DEA number: 2. Specialty Certification: The Nurse Practitioner is certified by the following organization (check all that apply): American Academy of Nurse Practitioners American Nurses Credentialing Center (ANCC) National Certification Board of Pediatric Nurse Practitioners and Nurses National Certification Corporation for the Obstetric, Gynecologic and Neonatal Specialties The Nurse Practitioner is qualified to practice in the following specialty areas (check all that apply): Gerontological Pediatric Adult Women s Health Care Family Neonatal Psychiatric Acute Care

14 COLLABATING PHYSICIAN INFMATION PAGE 2 OF 4 1. Identification: Physician Name (please print): Minnesota License Number Practice address(es): Practice telephone number: 2. Specialty Certification: The Physician, as identified above, is certified by the appropriate medical specialty certifying board, or has satisfactorily completed an approved residency training program, in the following medical specialty(ies) set forth opposite their name: Specialty: DESCRIPTION OF NURSE PRACTITIONER S PRACTICE 1. Description of practice: A descriptive statement of practice including the type of specialty of the Nurse Practitioner and collaborating Physician, type and scope of services, age and acuity of patients, geographic location, experience and specialty of the Nurse Practitioner and physician, etc. (attach additional page if necessary). 2. Drugs and Devices Nurse Practitioner is Authorized to Prescribe: DEA Certificate Status (answer appropriate question): I have a current DEA certificate and will be prescribing controlled substances. I do not have a DEA certificate and will not be prescribing controlled substances. Drug or Device Anesthetics (topical) Anesthetics (systemic) Anti-infectives Antihypertensive Medications Antiarrythmic Medications Antineoplastics Autonomic and Central Nervous System Drugs Blood Modifiers Cardiovascular Medications Complete a Provider Orders for Life Sustaining Treatment (POLST) form for appropriate patients Dermatological Medications Diagnostic Agents Ear-Nose-Throat Medications Electrolytes Endocrine Medications Gastrointestinal Medications Immunologic Medications Immunosuppressant Medications Medical Devices Musculoskeletal Medications Nutritional Products Specific Limitations (if none, write no limitations; if drug or device is not applicable, write NA )

15 Obstetrical and Gynecological Medications Ophthalmic Medications Order Diagnostic Radiology Respiratory Medications Urological Medications Vaccines PAGE 3 OF 4 PRESCRIPTIVE PRACTICE REVIEW The physician and Nurse Practitioner will regularly review the Nurse Practitioner s prescriptive practice to assure that the standard of care to which the physician is held is maintained which should specifically include the review of the prescriptive practice applicable to the privileges maintained by the Nurse Practitioner. The frequency and schedule for review of prescriptive practice shall be based on the nature of the practice, patient acuity, geographic location, experience and specialty of the provider and should occur, at a minimum annually as well as part of any ongoing OPPE evaluation. Agreed upon frequency and schedule of Nurse Practitioner s prescriptive practice review: Supervision of Clinical Activities As set forth in the applicable Nurse Practitioner Privilege form, supervision for day to day clinical activities of the Nurse Practitioner will be performed by the physician involved in the medical management of the patient or the physician(s) responsible for general oversight of the clinical activities of the particular specialty, service or clinical area as arranged and determined by the Nurse Practitioner and the involved physician(s). RESPONSIBILITIES and SIGNATURES Collaborating Physician: Supervise the performance of the delegated prescribing function through the review and discussion of the Nurse Practitioner s prescribing practices at the agreed upon frequency and schedule. Nurse Practitioner: Provide consultation to the Nurse Practitioner on the medical management of disease processes or other clinical management issues. Act within the Nurse Practitioner scope of practice as prescribed by law and within his/her individual practice agreement. Consult with the applicable supervising physician or collaborating physician as appropriate before prescribing if the Nurse Practitioner has any questions relating to his or her prescribing practice, such as questions regarding choice of drug and/or dosage.

16 SIGNATURES PAGE 4 OF 4 This Agreement shall continue in effect until terminated by either party on 30 days prior written notice. This Agreement shall terminate automatically upon the termination of employment of either the Nurse Practitioner or Physician. COLLABATING/SPONSING PHYSICIAN STATEMENT: I support the application for the above named individual for the privileges requested and agree to all of the terms, conditions and obligations associated with my collaborating/sponsoring said individual as specified in the policies and rules of the specific entity(s) to which the individual is applying. Collaborating/Sponsoring Physician Signature: Printed Name Physician Signature Date GROUP PRACTICE SPONSSHIP: In the event the above named individual for the services requested above will be sponsored by more than one practitioner in a group practice, the group practice (name of group) shall support the application of the above named individual for the privileges requested and agree to all the terms, conditions and obligations associated with the collaborating/sponsoring said individual as specified in the policies and rules of the particular entity(s) to which the individual is applying. The group practice represents that any practitioners providing the collaborating/sponsorship are members in good standing of the medical staff of the specific entity. Officer of Group Date Nurse Practitioner Signature: Printed Name Applicant Signature Date