How To Write A Nursing Care Plan

CERTIFIED NURSE PRACTITIONER STANDARD CARE ARRANGEMENT for ADVANCED PRACTICE NURSING between an employee of Mercy Medical Associates, LLC and, M.D / D.O. This Standard Care Arrangement ( SCA ) is made and entered into on, 20 (the "Effective Date") by and between an Advanced Practice Nurse ("APN") who will practice as a Certified Nurse Practitioner ("CNP") and is an employee of Mercy Medical Associates ( MMA ) and, M.D/D.O. ("Collaborating Physician") who hereby agree as follows: This SCA is a written formal guide for planning and evaluating the health care of clients cared for by Advanced Practice Nurses. This SCA has been developed in accordance with Section 4723.431 of the Ohio Revised Code and Rules adopted by the Board of Nursing for Advanced Practice Nurses. In compliance with The Joint Commission standards applicable to services provided through contractual arrangements, MMA and Collaborating Physician agree that Collaborating Physician's Services will be provided safely and effectively (LD 3.50) and that MMA must retain overall responsibility and authority for Services furnished under this Agreement (EP#7). This SCA shall be entered into prior to engaging in practice as an APN or when the collaborating physician(s) changes. In order to comply with the Ohio Revised Code, the SCA will be reviewed and signed by the APN and the Collaborating Physician on an annual basis. The most current copy of the SCA shall be retained and available upon request at all sites where the Advanced Practice Nurse practices. SECTION I: STATEMENT OF SERVICES The CNP may provide to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education and clinical experience. The CNP in collaboration with physicians or podiatrists may provide preventive and primary care services and evaluate and promote patient/client wellness within the nurse's nursing specialty, consistent with the nurse's education and certification, and in accordance with rules adopted by the Ohio State Nursing Board and section 4723.43 of the Revised Code. 1

Collaborating Physicians agree to maintain membership on the Medical Staff of one or more Mercy hospital and shall at all times during the term of this SCA be governed by and shall comply with the Medical Staff Bylaws and all rules, regulations and applicable policies of MMA, including, without limitation, the Catholic Directives. SECTION II: INCORPORATION OF NEW TECHNOLOGY OR NEW PROCEDURES The CNP will identify new technology/new procedures needed in his/her clinical practice. Educational inservices and conferences will be utilized as part of the process. SECTION III. QUALITY ASSURANCE PROVISIONS A. Criteria for Referral/Consultation of a Client The CNP, consistent with his/her clinical expertise and educational preparation shall determine when referral or consultation is necessary. Consultation options include, but are not limited to, telephone contact, on site case review or discussion and/or physical examination of the client by the Collaborating Physician. The method of consultation chosen and the resulting plan of care shall be documented in the patient's/client s record. The Collaborating Physician agrees to be continuously available to the CNP to communicate, consult and refer either in person or by radio, telephone or any other form of telecommunication available to or preferred by the CNP and Collaborating Physician. B. Procedure for Regular Review of Referrals to Other Health Professionals and Chart Review A random selection of patient/client records and patient/client referrals will be selected annually for review by the CNP and Collaborating Physician and/or a designated member of the quality assurance committee of the health care facility. Results of chart review will be documented. Care outcomes of referrals will be reviewed. C. Policy of Care of Infants and Children to Age Three Health care for the infant (older than 31 days) up to age one may be provided by either a CNP or physician. The CNP may not provide care for an infant less than 31 days of age. The American Academy of Pediatrics or the American Academy of Family Practice Standards of Care for infants up to age one will be followed. Collaborating Physician s visits for children from birth to age three will be at the determination of the CNP or Collaborating Physician. 2

D. Policy for Coverage of Absences In the event of a planned or unplanned absence by the CNP, scheduled patients/clients will be seen by another CNP or a Collaborating Physician. If this is not possible, scheduled patients/clients will be contacted and rescheduled. If the client requires more immediate attention he/she will be directed to the appropriate health care facility and health care provider. In the event of a planned or unplanned absence of the Collaborating Physician, the CNP will be notified by the Collaborating Physician and the Collaborating Physician will designate a physician colleague to cover in his/her absence. E. Policy for Resolution of Clinical Disagreements Should a disagreement arise between the CNP and the Collaborating Physician regarding diagnosis or treatment, one or more of the following means for resolution shall be followed: 1. Consult with another physician and/or CNP colleague (preferably within the clinical department, if one exists); 2. Refer to current professional literature (journals, research, and tests) appropriate to the area in question; 3. Consult with a specialist in the area of question; In the event that an agreement is not reached after the above steps, the parties agree to arbitrate. F. Arrangement Regarding Reimbursement Current state laws (including but not limited to O.R.C. 5111.02) and federal laws governing reimbursement will be adhered to. G. Insurance The Collaborating Physicians agree to carry and maintain (a) liability insurance in the amount of at least $1,000,000 per occurrence and $3,000,000 in the aggregate (or in any such other amount as required by the Board of MMA) and (b) such other insurance coverage as is customary in the Collaborating Physicians line of business or is reasonably requested by MMA. The insurance shall be carried at all times that the Collaborating Physicians are providing services pursuant to this SCA and must be obtained from an insurance company approved by MMA. The insurance company must also be a financially secure and viable liability insurance carrier which has been granted an A.M. Best Company rating of B+ or above (or an equivalent rating from a recognized national rating association and/or an appropriate actuarial opinion). In addition, Collaborating Physicians shall cause MMA to be named as an additional insured party under the policy or policies providing such insurance. Current policies, or certificates of insurance evidencing such policies, shall be provided to MMA upon request. Such policies or certificates shall provide that the insurance shall not be canceled or altered without 3

thirty- (30) day s prior written notice to MMA. The Collaborating Physicians further agree not to cancel or alter such insurance without thirty- (30) day s prior written notice to MMA. SECTION IV: ETHICAL AND RELIGIOUS DIRECTIVES The CNP and Collaborating Physician will abide by the Ethical and Religious Directives for Catholic Health Care Services, a copy of which is available at http://www.usccb.org/bishops/directives.shtml. SECTION V. TERM OF ARRANGEMENT This SCA is effective for a period of one year from the Effective Date noted above. This arrangement supercedes any other arrangements between the parties. This SCA can be terminated by either party, without cause and at any time, upon thirty- (30) day s prior written notice. This SCA shall be terminated immediately in the event the CNP is no longer employed by MMA. This SCA shall terminate immediately (i) if the Collaborating Physician fails to maintain appropriate clinical privileges to provide the services required under this Agreement, (ii) if the Collaborating Physician s license to practice medicine in the State of Ohio is restricted, suspended or revoked, (iii) upon the permanent disability of Collaborating Physician during the term of this SCA (A Collaborating Physician shall be deemed to be permanently disabled for purposes of this SCA when he has been unable to substantially perform the essential functions of the position under this SCA, due to illness or accident, with or without reasonable accommodations for a period of time in excess of ninety (90) -days within any one hundred eighty (180) -day period.) (iv) if the insurance maintained by the Collaborating Physician has been or will be reduced below the minimum levels set forth in this SCA, or has been or will be canceled, (v) if the Collaborating Physician is currently or during the term of this SCA becomes excluded from Medicare or (vii) if Collaborating Physician breaches any material term of this Agreement, including but not limited to the business associate section. SECTION VI: CORPORATE RESPONSIBILITY PROGRAM Collaborating Physician acknowledges that MMA has established a Corporate Responsibility Program (CRP) and promotes a culture that fosters prevention, detection and resolution of instances of misconduct. Collaborating Physician shall immediately notify MMA's Corporate Responsibility Officer of any violation of any applicable law, regulation, third party payor requirement or breach of MMA's CRP of which Collaborating Physician becomes aware of during the term hereof. Collaborating Physician shall cooperate with MMA in responding to or resolving any complaint, investigation, inquiry or review initiated by a governmental agency or otherwise. Collaborating Physician shall cooperate with any insurance company providing protection to MMA in connection with the foregoing. In connection with the foregoing, Collaborating Physician shall, consistent with applicable law, fully follow the directions of MMA 4

SECTION VII: BUSINESS ASSOCIATE UNDER HIPAA (a) As a business associate of MMA, Collaborating Physician shall ensure that patient identifiable health information provided by MMA will be treated as confidential and kept secure in accordance with applicable law and the Health Insurance and Portability and Accountability Act of 1996 ( HIPAA ). Specifically, Collaborating Physician agrees that it will comply with the following in accordance with the timeframes specified in the regulations: (i) Collaborating Physician shall maintain administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of patient identifiable health information, in electronic or other form, that it creates, receives, maintains or remits under the Agreement, in accordance with the Privacy Rule (45 C.F.R. Part 160 and Part 164, subparts A and E and amendments thereto) and in accordance with the Security Rule (45 CFR Part 164, Subpart C and amendments thereto) to prevent access, use or disclosure of patient identifiable health information in violation of the law or this Agreement: (ii) Collaborating Physician agrees that it shall be prohibited from using or disclosing the patient identifiable health information provided or made available by MMA for any purpose other than as expressly permitted or required by this Agreement or as required by law; (iii) Collaborating Physician shall ensure that any subcontractor or agent to whom Collaborating Physician may disclose the patient identifiable health information to is bound by the confidentiality terms and conditions of this Agreement including appropriate and complete safeguards, as defined in paragraph Section VIII (a) (i) above; (iv) Collaborating Physician shall make available to MMA and the US Department of Health and Human Services its policies and procedures, books, and records and information practices relating to its use of the patient identifiable health information; and (v) Collaborating Physician shall promptly notify MMA in writing of any use or disclosure of the patient identifiable health information outside the purpose of this Agreement; MMA shall respond to the notice within three (3) business days approving or denying such disclosure. (vi) Collaborating Physician hereby agrees to make available and provide a right of access to the patient identifiable health information by the patient who is the subject of the patient identifiable health information. This right of access shall conform and meet all of the requirements of 45 CFR 164.524. 5

(vii) Collaborating Physician agrees to make patient identifiable health information available for amendment by a patient who is the subject of the patient identifiable health information and to forward immediately to MMA any request by such a patient to make amendments to their patient identifiable health information, and to incorporate any amendments to such patient identifiable health information provided by MMA to Collaborating Physician, in accordance with 45 CFR 164.526, (viii) At the termination of this Agreement, Collaborating Physician hereby agrees to return or destroy all patient identifiable health information received from, or created and received by Collaborating Physician on behalf of MMA. Collaborating Physician agrees not to retain any copies of the patient identifiable health information after termination of this Agreement. If return or destruction of the patient identifiable health information is not feasible, Collaborating Physician agrees to extend the protections of this Agreement for as long as necessary to protect the patient identifiable health information and to limit any further access, use or disclosure. If Collaborating Physician elects to destroy the patient identifiable health information, it shall certify to MMA in writing that the patient identifiable health information has been destroyed. (ix) As noted in the termination section of this Agreement, Collaborating Physician agrees that MMA has the right to immediately terminate the Agreement and seek relief if MMA determines that Collaborating Physician has violated a material term of this Agreement. (b) MMA and Collaborating Physician agree to use best efforts to maintain the integrity, confidentiality and security of electronically transmitted information. (c) MMA and Collaborating Physician further agree that in the event of a conflict between the business associate provisions herein and other provisions of this Agreement the business associate provisions shall control. (d) For any psychoanalysis records (as such term is defined within the HIPAA regulations) both parties agree to abide by HIPAA requirements concerning such records. SECTION VIII: DRUGS TO BE PRESCRIBED [Applicable only to APNs with Prescriptive Authority.] Upon acceptance into the Ohio Advanced Practice Pilot Program, the CNP utilizes the prescriptive protocols developed by the Formulary Committee for Advanced Practice Nurses in the Pilot Programs (Formulary Committee). In accordance with the Certified Nurse Practitioner s scope of specialty practice, the prescriptive protocols for Adult, Pediatrics, Obstetrics and Gynecology, and Geriatrics are utilized in providing care to patient/client populations served by the CNP, Professional discretion of the Collaborating Physician and CNP is utilized at all times. Any drugs that are prescribed outside of existing protocols are prescribed by the Collaborating Physician. 6

As applicable upon attaining a Certificate to Prescribe (CTP) from the Ohio Board of Nursing, APN and Collaborating Physician shall ensure a plan or process to: (a) Assure timely face-to-face evaluation of a patient by the Collaborating Physician or designee. (b) Set prescribing parameters, if applicable, for off-label prescribing. (c) Conduct at least semi-annual review of prescriptions by the APN and Collaborating Physician. (d) Set up any additional prescribing parameters determined by the APN and Collaborating Physician to be necessary. In accord with the Formulary approved by the Ohio Board of Nursing, any APN holding a Certificate to Prescribe and his/her Collaborating Physician shall review the Formulary and specify on the Formulary whether a drug or drug category listed as Physician Initiated (PI) or Physician Consult (PC) will require the Collaborating Physician to personally examine the patient (PI) or if the drug may be prescribed with consultation (PC). This determination shall be consistent with the APNs scope of practice and the practice specialty of the Collaborating Physician. Non-Exclusion/Conviction. Collaborating Physician represents and warrants to MMA that (a) he is not excluded from participation in any federal health care program, as defined under 42 U.S.C. 1320a-7b (f), for the provision of items or services for which payment may be made under such federal health care programs or (b) he has not been recently convicted (as that term is defined under 42 U.S.C.. 1320a (7)(i)) of a criminal offense related to health care. Collaborating Physician represents and warrants to MMA that no final adverse action, as such term is defined under 42 U.S.C. 1320a-7e (g), has occurred or is pending or threatened against such Collaborating Physician. [REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK] 7

Advanced Practice Nurse Certified Nurse Practitioner Name Specialty Practice Area Phone (work) Phone (home) Emergency Phone Primary Collaborating Physician Name Emergency Phone Additional Collaborating Physician(s) Name Name _ Date SCA Executed: Date SCA Reviewed: Date SCA Reviewed: Date SCA Reviewed: 8

Additional Collaborating Physician(s) Name Name _ Additional Collaborating Physician(s) Name Name _ Date SCA Reviewed: Date SCA Reviewed: 9

Date SCA Reviewed: Date SCA Reviewed: Additional Collaborating Physician(s) Name Name _ Additional Collaborating Physician(s) Name Name _ 10