COLLABORATIVE AGREEMENT CHECKLIST
GENERAL INFORMATION:
Collaborating Physician: ______License Number: ______
CRNP: ______License Number: ______
Clinic Address: ______Zip Code: ______
COLLABORATION REQUIREMENT [Rule 540-x-8-.08 (4) (a-e)]:
For the CRNP with less than (2) years (4000 hours) of collaborative practice experience:
_____Collaborating Physician has been present for not less than ten percent (10%) of the CRNP’s scheduled hours in an approved practice site.
For the CRNP with (2) years (4000 hours) of collaborative practice experience:
_____Collaborating Physician has met with CRNP no less than quarterly
Remote Practice Sites
_____Collaborating Physician has visited remote practice sites no less than twice annually.
Required for ALL Collaborative Practice Agreements:
_____Collaborating Physician has providedMedical Oversight during this quarter.
[540-x-8-.01 Definitions (12) Medical Oversight]: “Concurrent and on-going collaboration between a physician and a CRNP or CNM and documentation of time together in a practice site; may include but is not limited to direct consultation and patient care, discussion of disease processes and medical care, review of patient records, protocols and outcome indicators, and other activities to promote positive patient outcomes”.
QUALITY MONITORING PROCESS:
_____Collaborating Physician has completed Quality Assurance Reviews no less than quarterly.
[540-X-8-.01 Definitions (13) Quality Assurance]: “Documented evaluation of the clinical practice of the certified registered nurse practitioner or certified nurse midwife against defined quality outcome measures, using a selected, meaningful sample of patient records which will identify areas needing improvement, set performance goals, and assess progress towards meeting established goals, with a summary of findings, conclusions, and, if indicated, recommendations for change. The physician’s signature on the patient record does not constitute quality improvement monitoring”
_____Quality Assurance outcome measures are defined and documented.
______Quality Assurance meetings between physician and nurse practitioner to discuss summary of findings, conclusions, and any recommendations for change are documented.
Dates of most recent Quality Assurance Monitoring meetings:
Date: ______Quality measure discussed: ______
Date: ______Quality measurediscussed: ______
Date: ______Quality measurediscussed: ______
COVERING PHYSICIANS:
[Rule 540-X-8-.08 (2)] “In the event the collaborating physician is not readily available, provisions shall be made for medical coverage by a physician who is pre-approved by the Board of Medical Examiners and is familiar with these rules”.
[Rule 540-X-8-.08 (e)] “Allow a pre-approved covering physician to be present in lieu of the collaborating physician”
List found on Collaboration Details required at each site
DOCUMENTS REQUIRED ON SITE:
The following documents are current and copies present in all sites where the nurse practitioner will work:
______Copy of Collaborative Agreement Details (CRNP Individual Profile)
______Copy of Approval Notice from ABN
______Copy of Collaborative Practice Registration Certificate from BME
______Copy of RN Primary Source Verification (ABN website)
______Copy of CRNP Certification showing expiration date
______Policy detailing Emergency Plan and provisions
______Policy and process for referral by CRNP to a physician other than collaborating physician
______Copy of Standard Protocol for Nurse Practitioner Specialty indicating competency validation
______Copies of any Specialty Protocol approvals including documentation of training for CRNP (if applicable)
______Copies of any Specialty Formulary approvals (If applicable)
CONCLUSIONS:
Compliance Issues : ______
Date of this Internal Collaborative Practice Review: ______
Reviewer Name: ______Signature: ______