(Bold face states the new rule; the suggested template follows the bold face)

1. Nature of practice/patient population/setting: Broadly describe the type of practice (e.g., family; pediatric), the patient population (e.g., elderly; college students) and setting (e.g, nursing home; college health center).

2. Any particular circumstance for which, prior to prescribing, a specific examination is to be performed or a definitive diagnosis made: APNs at (this practice site) perform assessments of patients including history taking and physical examination prior to prescribing based upon the individual needs of patients in accordance with rights and privileges granted through RN licensure and APN certification by the New Jersey Board of Nursing. The nature and extent of assessments performed and resultant diagnoses made by APNs follow accepted standards of Advanced Nursing Practice.

3. Recordkeeping methodology: At (this practice site) every patient encounter requires a dated entry in the patient's record using (specify the format utilized in the practice, such as SOAP).

4. A list of categories of medications appropriate to the practice: New Alert: P.L. 2004, c. 122, the new APN law which granted APNs unrestricted authority to prescribed controlled substances, requires that APNs specifically state in their Joint Protocol whether or not consultation with the collaborating physician is required prior to prescribing or ordering controlled substances. Additionally a new “Blood Bank” regulation: N.J.A.C. 8:8-1.2 permits APNs to prescribe or order blood or blood products,” consistent with language in their Joint Protocol). APNs may prescribe and/or dispense all medications and devices, including controlled substances (if this is what the APN and collaborating physician have agreed to) without prior physician consultation. (List desired exceptions; list blood or blood products, if relevant).

5. A delineation of specific medications and the specific number of refills to be prescribed pursuant to the direction of the physician: APNs will consult with the collaborating physician regarding the specific number of refills of a particular medication whenever, in the APNs professional opinion, the patient's condition warrants physician consultation.

6. Specific requirements with respect to the recordation in the patient record of medications prescribed or dispensed, etc.: Medications and devices either prescribed or dispensed by APNs will be recorded in the patient's record noting date, name of drug or device, dosage, quantity, frequency, duration, instructions for patient use and authorization for refills, if any.

7. Any medical conditions or findings within the nature of the practice which should require direct consultation prior to the prescribing or ordering of medications or devices: APNs will communicate with the collaborating physician prior to prescribing medications or devices when, in the APN's professional opinion, the patient's condition requires physician consultation or intervention.

8. The frequency and methodology to be employed to ensure periodic review of patient records: Joint review of (X number) of patient records shall occur on at least an annual basis (include a brief statement of the procedures utilized at this site).

9. Identification of the means by which the advanced practice nurse and collaborating physician can be in direct communication, as well as a description of arrangements which will assure that the collaborating physician or peer coverage is accessible and available: The collaborating physician is available to consult with the APN at all times, either in person or via electronic means. The collaborating physician will arrange for peer coverage in his/her absence from the practice.

10. Procedures for the use of medications in emergency situations: Procedures for the use of medication in emergency situations will be based upon accepted standards of nursing practice in accordance with rights and privileges granted through RN licensure and APN certification. Procedures for emergency care at (this site) are available in writing in X handbook (list any procedures in place by title).

11. Identification of reference materials containing practice guidelines or accepted standards of practice: Clinical references used by the APN and the collaborating physician as guidelines to prescriptive practice include but are not limited to the following: (list references).



*As per requirement of N.J. Division of Consumer Affairs for "Standards for Joint Protocols between Advanced Practice Nurses and Collaborating Physicians," New rules: N.J.A.C. 13:35-6.6 and 13:37-6.3. Adopted 6/2/00; Operative 9/1/00