IC ollaborative Practice Agreement by g5dV1FFY


									        Ongoing Review of Care and Quality Improvement Record
This serves as a record of regularly scheduled meetings between the Primary Supervising Physician
and the Advanced Practice Provider (Nurse Practitioner(NP)/Physician Assistant(PA)). The
schedule for quality reviews will be monthly for 6 months and then every 6 months thereafter.
Both will maintain copies of the record for five calendar years.

1. Clinical Case:

2. Review of History:

3. Review of Physical Assessment:

4. Differential Diagnosis, Plan, and Disposition

5. Recommendations for Improvement

6. Improvement Plan and Time Line:

Nurse Practitioner/Physician Assistant                                              Date

Primary Supervising Physician                                                       Date

Duke Department of Advanced Clinical Practice, March 2010

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