Sonoma State University Department of Nursing Family Nurse Practitioner Program

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1 Sonoma State University Department of Nursing Family Nurse Practitioner Program OB Preceptor Packet N550ABC Rev 8/05 WAS

2 Department of Nursing 1801 East Cotati Avenue, Rohnert Park, California / LETTER OF AGREEMENT N550ABC Please print Date: Preceptor Name Agency Name Phone Number: ( ) Address Fax Number ( ) City, State, Zip This letter is to confirm arrangements for, FNP student, to do preceptorship study in obstetrics with you. The student will spend hours per week in your office during each semester of preceptorship, depending upon your office hours. It is anticipated that this arrangement will be in effect from to, however, either party with 14 days notice can terminate it. Your responsibilities include clinical supervision and instruction as needed, and a written evaluation of student performance at the end of each semester. Evaluation forms are attached. The student s faculty advisor generally visits the student s primary clinical site 1-2 times per semester for observation of student progress and for discussion of the experience. Though these visits are usually made to the student s family practice site, a specialty site is occasionally visited as well. The student s written evaluations from all sites are then used to arrive at a final clinical grade for each semester. When the student begins the experience in your office, he or she will be knowledgeable in normal prenatal and post-partum care and management of common complaints of pregnancy. Throughout the program they will continue to learn evaluation and management of complications of pregnancy. The FNP students function under their RN license within the stipulations of Article 2, Section 2725 of the California Nursing Practice Act (BPC Chapter 6). The course content provides general guidelines for chart management. These serve as general guidelines for practice; however, in your office, students are expected to consult you and follow your approaches to treatment. All nursing students are covered by the school s blanket liability insurance policy, in the amount of $1million/$3million. Worker s compensation insurance is provided by the CSU Risk Pool to respond for injuries sustained by the student while participating in the clinical nursing experience at the preceptorship site. This letter serves as an agreement between yourself and the Sonoma State University Department of Nursing, unless there are other changes you desire. Should you have any questions about the preceptorship, please do not hesitate to call. Chair, Dept. of Nursing FNP Program Director Preceptor Signature

The student will spend hours per week in your office during each semester of preceptorship, depending upon your office hours.

3 SONOMA STATE UNIVERSITY Department of Nursing FNP Preceptorship Date: If you prefer, you may submit a CV in lieu of this form, if the CV contains the information contained in this form. CLINICAL PRECEPTOR VITAE (BRIEF) NAME: PHONE NO.: AGENCY: Type of License: License No. Expires: SCHOOL TRAINING INCLUDING COLLEGE OR UNIVERSITY & OTHER SCHOOLS IN SPECIAL SUBJECTS: Name of School Location Dates Attended Degree or Diploma SPECIAL & PRIVATE TRAINING: Name of Institution Dates Attended Subjects Covered Credit Equivalent CLINICAL EXPERIENCE: Type: LENGTH OF EXPERIENCE:

Expires: SCHOOL TRAINING INCLUDING COLLEGE OR UNIVERSITY & OTHER SCHOOLS IN SPECIAL SUBJECTS: Name of School Location Dates Attended Degree or

4 MEMBERSHIPS IN PROFESSIONAL ORGANIZATIONS: INTEREST AREAS IN WORKING WITH STUDENTS: I certify that the information provided is accurate and complete to the best of my knowledge and belief: Signature: Date: PLEASE ATTACH A COPY OF YOUR LICENSE NOTICE TO PRECEPTORS Clinical adjunct professor status is available to our preceptors if desired. It is a courtesy title without remuneration, and is designed to provide recognition of your valuable contribution to our students and our program. Should you desire such an appointment, please check here and complete the following: SOCIAL SECURITY NUMBER: EMERGENCY CONTACT INFORMATION NAME: STREET ADDRESS: CITY: STATE: ZIP: PHONE:

desired. It is a courtesy title without remuneration, and is designed to provide recognition of your valuable contribution to our students and our program.

5 Upon completion of OB preceptorship, the student will be able to: A. In physical diagnosis and nurse practitioner assessment process: 1. Conduct a thorough intake history and physical exams pertinent to the new prenatal client. 2. Obtain appropriate interim history at routine prenatal visits. 3. Assess normal progression of pregnancy using standard parameters, i.e. urine dipstick, BP, fundal height measurements, fetal heart tones, fetal movements, etc. 4. Order and interpret lab studies appropriately at various stages of pregnancy. 5. Perform pelvic exams when necessary, including cultures/wet mounts, using proper technique. 6. Assess psychosocial issues affecting pregnancy, birth and parenting. 7. Assess for actual/potential complications of pregnancy. 8. At post-partum visit, gather pertinent data related to labor and delivery, problems/concerns, general adaptation and adjustment to parenting. B. In management of health/illness conditions: Provide patient education regarding normal physiological change of pregnancy, fetal growth and development, and diet and exercise in pregnancy. Educate the patient regarding use of caffeine, alcohol, tobacco, medications or illicit drugs during pregnancy and breastfeeding.] Explain lab tests or procedures being ordered. Manage common complaints of pregnancy. Educate patients regarding danger signs appropriate to gestational age and/or puerperium. Consult and refer patients appropriately based on history and physical exam finding/concerns. Include psychosocial care and counseling as necessary. Record accurately using problem oriented recording and/or forms when appropriate. C. In role identity and professional development: 1. Interpret the role of the FNP to clients and professionals. 2. Establish a professional relationship with preceptor, staff, and clients. 3. Present cases to preceptor in a clear, concise, and pertinent manner. 4. Accept responsibility for own learning.

Assess normal progression of pregnancy using standard parameters, i.e. urine dipstick, BP, fundal height measurements, fetal heart tones, fetal movements, etc. 4.

6 OB CLINICAL EVALUATION FORM Student Preceptor Date: Site ASSESSMENT PROCESS A B C D E N/ A 1. Gathers appropriate history 2. Uses good exam technique and is able to identity normal vs. abnormal finding in the following areas: a. pelvic exam b. McDonald s measurements c. Fetal heart tone d. BP, urine dipstick, edema e. Begins to perform Leopold s maneuvers correctly 3. Explores psychosocial concerns appropriately 4. Orders and interprets lab tests appropriate to gestational age and/or acute problems 5. Knows indications for special diagnostic tests, i.e. U/S, NST, etc. Comments: MANAGEMENT OF HEALTH AND ILLNESS A B C D E N/ A 1. Manages common complaints of pregnancy 2. Provides patient education re: a. normal progression of pregnancy b. diet and exercise c. caffeine, ETOH, tobacco, drug use d. preparation for labor, delivery, and parenting 3. Identifies actual/potential risk of complication to pregnancy 4. Provides counseling as needed 5. Plans for appropriate follow-up and/or referral Comments:

Explores psychosocial concerns appropriately 4. Orders and interprets lab tests appropriate to gestational age and/or acute problems 5. Knows indications for special diagnostic tests, i.e. U/S, NST, etc.

7 OB CLINICAL EVALUATION FORM Page 2 ROLE IDENTITY AND PROFESSIONAL RELATIONS 1. Interprets the FNP role to patients and other professionals 2. Presents cases to consultant in a clear, well-organized manner 3. Develops effective relationships with preceptors, staff and patients 4. Accepts responsibility for own learning A B C D E N/A Comments: Preceptor signature Date

Presents cases to consultant in a clear, well-organized manner 3.

Home Health Agencies. Ante & Postpartum Members

Home Health Agencies. Ante & Postpartum Members FIRST PRIORITY HEALTH /FIRST PRIORITY LIFE INSURANCE COMPANY BLUE CROSS OF NORTHEASTERN PENNSYLVANIA CREDENTIALING CRITERIA FOR OBSTETRIC NURSES IN HOME CARE ADMINISTRATIVE PRACTICE GUIDELINE PROVIDER