Policy Title/Number

/ Protocol Number / PL xx-xxx-xx
Protocol: Advanced Practice Nursing / Effective Date / Month/Year
Service Line: / Add appropriate service line here / Supersedes / Month/Year
Add name of protocol here in bold
Key Words: For search purposes, add appropriate key words
Practice Site Location(s)
VUH / Children’s / DOT / VMG Off-site locations / VMG / VPH / Other
Developed & Approved by
Name: Date
Title: / Name: Date
Title:
Name: Date
Title: / Name: Date
Title:

Table of Contents

I. Population: 1

II. Indications: 1

III. Definitions: 2

IV. Additional Competencies Required: 2

V. Assessment: 2

VI. Diagnostic Data: 2

VII. Differential Diagnosis: 3

VIII. Goals of Treatment: 3

IX. Intervention/Treatment: 3

X. Complications: 4

XI. Medications by Formulary: 4

XII. References: 4

I. Population:

Define target patient population here

II. Indications:

Insert brief statement regarding indication(s) for use of protocol.

III. Definitions:

A. Insert definitions here if indicated for this protocol

B. If there are no definitions, write “None” in this section.

IV. Additional Competencies Required:

A. Insert competency detail here if indicated for this protocol.

B. If there are no Additional Competencies Required, write “None” in this section.

V. Assessment:

A. Physical Exam: describe typical physical exam findings for disease process

B. History: describe typical history findings for disease process

VI. Diagnostic Data:

Describe typical diagnostic data to be obtained (lab, radiology, other diagnostics)

VII. Differential Diagnosis:

List other possible diagnoses requiring “rule out” and/or further evaluation.

VIII. Goal(s) of Treatment:

Expected outcomes related to treatment of disease process

IX. Intervention/Treatment:

A. List specific interventions and treatments

B. Include criteria for when to consult physician:

X. Complications:

List specific complications for disease process and treatment; include monitoring criteria and specific interventions for complications

XI. Medications by Formulary:

List medications by formulary typically used in conjunction with this procedure (include pre-procedure medications and discharge medications)

XII. References:

List relevant references used in the development of the protocol

Use APA format [for assistance, visit http://owl.english.purdue.edu/owl/resource/560/01/]