In order to provide the highest standard of care for the patients of Gastroenterology Associates, this document provides an outline of the resources and specific protocols to be used by the nurse practitioner in accordance with the Rules and Regulations established by the North Carolina Board of Nursing and Board of Medicine. It is the intent of this document to authorize the nurse practitioner, , FNP-C, to follow the identified protocols within the direct supervision or approval of a physician. The following outlines the scope of practice for the nurse practitioner: 1. Consultative services provided to the patients ages 16 to 100+ at Cabarrus Gastroenterology Associates. 2. History and physical, promotion and maintenance of health, patient counseling and education. 3. Diagnosis, treatment and management of acute and chronic illnesses. 4. Prescribing, administering and dispensing therapeutic measures, tests, procedures and drugs. 5. Planning for situations beyond the nurse practitioner’s expertise, and consulting with and referring to other health care providers as appropriate. 6. Evaluating health outcomes. However, physician consultation will be sought for the following situations and any other situations she deems necessary including: 1. Situations which go beyond the competency or scope of practice of the nurse practitioner. 2. Patient conditions which fail to respond to prescribed treatment within the protocol time frame 3. Situations which do not fit the commonly accepted diagnostic patterns for a given disease or disorder. 4. All emergency situations and unstable patient conditions which require the immediate attention of a physician. 5. Other situations deemed necessary. The case management of patients, including diagnosis, treatment, and documentation of care, will reflect currently accepted standards of medical and nursing practice as stated in this document. A complete list of books and manuals of protocols approved for use in assessment, diagnosis, treatment, evaluation by the nurse practitioner by Dr. is included in Appendix A. The nurse practitioner is authorized to order lab work and diagnostic studies for disease diagnosis and management as outlined in the protocol manuals and books included in Appendix A. The nurse practitioner is authorized to initiate consultation or referral to a physician, psychologist, psychiatrist, podiatrist, dentist and social worker. The referral will be noted in the chart.

The nurse practitioner is authorized to prescribe drugs and devices in accordance with the rules and regulations governing prescriptive authority for Licensed Nurse Practitioners in the state of North Carolina, which states: "Controlled Substances (schedules II, IIN, III, IIIN, IV, V) defined by the State and Federal Controlled Substances Acts may be procured or ordered as established in written standing protocols, providing all of the following requirements are met: a) The nurse practitioner has an assigned DEA number which is entered on each prescription for a controlled substance; b) dosage units for schedules II, IIN, III and IIIN are limited to a 30 day supply; and c) the prescription or order for schedules II, IIN, III and IIIN may not be refilled; d) refills may be issued for a period not to exceed one year except for schedule II, IIN, III, and IIIN controlled substances which may not be refilled." All written and verbal prescriptions will be noted in the patient's chart and including the following information: medication & dosage, route, amount prescribed, directions for use, number of refills, and signature of nurse practitioner. Emergency services will be initiated by the nurse practitioner in the absence of the physician as follows: notify the supervising physician via the phone/pager, call 911 and initiate ACLS if necessary. The nurse practitioner which has been previously approved to practice in North Carolina who changes primary supervising physician shall have face-to-face consultation with her primary supervising physician weekly for one month and then monthly for succeeding five months. Documentation of consultation shall: identify clinical issues discussed and actions taken; be signed and dated by those who attended and be available for review by members of either Board. This document is in accordance with the Rules and Regulations established by the joint Board of Nursing and Board of Medicine who authorize licensing of nurse practitioners in the state of North Carolina. The protocols were jointly reviewed and approved by the supervising physician, Dr. and the Licensed Nurse Practitioner. By signing this statement of approval, we the below named nurse practitioner and physicians agree to abide by the standardized protocols and rules and regulations that govern the scope of practice of the Nurse Practitioner while caring for patients at Gastroenterology Associates.



, M.D.




Appendix A PROTOCOL RESOURCE LIST (May Be Revised Periodically) The following sources are intended to guide not dictate practice. Departures from guidelines that address the “typical patient and/or condition may occur when individualizing care to a particular client/family and situation. Care delivered by the Nurse Practitioner will reflect, but not be limited to the following nursing, medical and interdisciplinary sources: American Journal of Gastroenterology American Journal of Nursing American Nurse’s Association Social Policy Statement, Standards of Clinical Nursing Practice, Scope and Standards of Advanced Practice Registered Nursing, and Code for Nurses Clinical Guidelines in Family Practice by Uphold and Graham Clinical Laboratory Medicine: Clinical Application of Laboratory Data by Ravel Clinician’s Handbook of Preventive Services by the United States Department of Health and Human Services and the Public Health Service. Conn’s Current Therapy by Rakel Consultations Gastroenterology by Snape Drug Facts and Comparison by Facts and Comparisons Gastrointestinal Disease by Sleisenger, Schargehmidt, and Feldman Goodman and Gilman’s Pharmacological Basis of Therapeutics by Gilman, Rall, Nies and Taylor Handbook of Gastroenterology by Yamada Journal of the American Academy of Nurse Practitioners Manual of Medical Therapeutics, The Washington Manual by Ewald and McKenzie Master’s preparation in Family Health Nursing North Carolina Nurse Practice Act Nurse Practitioner: The American Journal of Primary Health Care Patient Care: the Practical Journal for Primary Care Patient Care Guidelines for Nurse Practitioners by Hoole, Axalla, Pickard, Ouimette, Lohr, and Greenberg Practical Gastroenterology Primary Care Medicine: Office Evaluation and Management of the Adult Patient by Goroll, May, and Mulley

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