IC ollaborative Practice Agreement by g5dV1FFY

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									        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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