Nurse Practitioner Health Care

Location:

Gardena, CA

Posted:

October 07, 2024

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Resume:

NURSE PRACTITIONER

GENERAL POLICIES

AND

STANDARIDZED PROCEDURES

TABLE OF CONTENTS

Introduction to Standardized Procedures 3 Statement of Approval and Agreement 4 General Policies

Development, Revision, and Review 5 Approval and Agreement 5

Record of Authorized Nurse Practitioners 5 Evaluation of Clinical Care 6 Supervision 6

Consultation 6

Office Oversight 6

Specialist Referrals 7 Patient Records 7

Education and Training 7 Setting 7

Health Care Management Standardized Procedures

Health Care Management-Primary Care 8-9 Health Care Management-Secondary Care 10-11 Health Care Management-Tertiary Care 12-13 Procedures and Minor Surgery 14-15 Health Promotions Exams 16-17 Ordering Lab Work/Diagnostic Studies 18-19 Ordering Therapies 20

Dispensing Medications 21-22 Medication Management 23-24 Furnishing Drugs and Devices 25-26 Formulary 27

Appendix I (Scope of Regulation and Dispensing Nurse Practice Act) 28-30 Appendix II (Standardized Procedure Guidelines Nurse Practice Act) 31-32 Appendix III (Furnishing Business and Professions Code) 33-35 Appendix IV (Container Labeling Requirements) 36 References 37

INTRODUCTION TO STANDARDIZED PROCEDURES

The purpose of Standardized Procedures is to define the scope of practice of Nurse Practitioners

(NPs) in order to meet the legal requirements for the provision of healthcare by Nurse Practitioners at Desert Oasis Healthcare’s (DOHC) Group. Standardized Procedures are established to assist all healthcare providers with an understanding of the role and scope of practice of the nurse practitioner and to provide a safeguard so that providers and patients alike may be assured of the best healthcare possible.

These Standardized Procedures are based on the Guidelines established by the Board of Registered Nursing.

In order to provide the highest standard of care, these Standardized Procedures incorporate the following qualities:

o ADAPTABILITY, in order to allow for the unique management needs of each individual patient,

o FLEXIBILITY, to accommodate the rapidly changing and complex nature of the health care field and to acknowledge that medicine is not an exact science, o PRACTICALITY, in order to be useful in a setting that must incorporate a variety of educational backgrounds and personal management styles, and o SPECIFICITY, to address the intent of the Standardized Procedure Guidelines, which are meant to protect the health care consumer.

Standardized Procedures consist of the following:

GENERAL POLICIES: Define the general conditions of and give authorization to the Nurse Practitioner to implement Standardized Procedures. HEALTH CARE MANAGEMENT STANDARDIZED PROCEDURES: Delineate the medical functions requiring a standardized procedure and, using policies and protocols, define the circumstances and requirements for their implementation by the nurse practitioner. 4

STATEMENT OF APPROVAL AND AGREEMENT

This document is in accordance with the requirements of the California Business and Professions Code, Sec. 2725 (see Appendix I) and the California Administrative Code, Sec. 1474 (see appendix II) regulating nursing practice. It was jointly derived by the nurse practitioners, their supervising physicians and Management of Desert Oasis Healthcare Medical Group. By signing this Statement of Approval, we agree to maintain a collaborative and collegial relationship, and abide by Standardized Procedures and Protocols in theory and practice. APPROVAL OF COLLABORATING PHYSICIAN(s):

PATRICIA SOTOLONGO, DO Date

APPROVAL OF ADVANCE REGISTERED NURSE PRACTITIONER(s): LEA PASCUAL, FNP-BC Date

10/3/2024

GENERAL POLICIES

It is the intent of this document to authorize Desert Oasis Healthcare (DOHC) Group’s Nurse Practitioners (NPs) to perform Standardized Procedures without the immediate supervision or approval of a physician. Standardized Procedures, including all policies and protocols, are defined in this document and will be referred to generally as “Standardized Procedures.” It is not the intent to have nurse practitioners independently diagnosing, treating or managing all the patient conditions they might encounter, but rather to utilize their assessment and health care management skills in conjunction with Standardized Procedures and the collegial physician-nurse practitioner relationship, in order to meet the health care needs of the patients. DEVELOPMENT, REVISION AND REVIEW

Standardized Procedures are developed collaboratively by NPs, physicians and administration from DOHC. Revisions are performed, reviewed and approved as needed. At a minimum, all Standardized Procedures will be reviewed and approved every three years and as practice changes by the Inter-Disciplinary Practice Committee (IDPC). APPROVAL AND AGREEMENT

All nurse practitioners and associated physicians will signify their agreement with Standardized Procedures by following the review and approval process. Signature on the Statement of Approval and Agreement implies the following: a. approval of all the policies and protocols in this document, b. the intent to abide by the Standardized Procedures, and c. the willingness to maintain a collegial and collaborative relationship with all the parties. Nurse practitioners and physicians who join the staff mid-year or who cover the practice must also approve the Standardized Procedures. It is the task of the physician to see that written agreement by all the above parties is obtained.

RECORD OF AUTHORIZED NURSE PRACTITIONERS

The Statement of Approval and Agreement signed by the Nurse Practitioners will act as the record of nurse practitioners authorized to implement Standardized Procedures. All NPs employed by DOHC will be provided a copy of the “Standardized Procedures and Protocols.” Upon review, the NPs will sign the “Statement of Approval” signifying their acceptance and willingness to abide by them.

EVALUATION OF CLINICAL CARE

Evaluation of the nurse practitioner will be provided in the following ways:

• Initially, all medical records will be reviewed by a physician for a minimum of two weeks

• Subsequently, there will be periodic chart reviews by a physician as part of the monitoring process.

• Annually, there will be a written evaluation of performance based on DOHC format.

• Consistently, there will be on-going informal evaluation during consultations 6

SUPERVISION

The nurse practitioner is authorized to implement standardized procedures identified in this document without the direct or immediate observation, supervision or approval of a physician. Physician consultation is available at all time, either on-site or by electronic means. CONSULTATION

The nurse practitioner will manage Primary, Secondary and Tertiary care conditions as outlined in this document.

The process of consultation includes presentation of the patient’s status to the physician by the NP; collaboration on examination, assessment and intervention as deemed appropriate; and authorization is reflected in the chart by physician signature and/or citation of consulting physician by the NP.

Physician consultation will be sought for all the following situations and any other deemed appropriate:

• Emergency conditions requiring prompt medical interventions.

• Acute decomposition of patient situations.

• Problems that are not resolving as anticipated.

• Unexplained historical, physical or laboratory findings.

• Upon request of the patient, NP or physician and appropriate facility staff. When a physician is consulted, the NP is to make a notation in the chart to that effect. OFFICE OVERSIGHT

Office oversight protocols should specify clinical and behavioral factors that should mandate immediate consultation with the supervising physician. While each practice will have different specific criteria, general themes include:

• Signs or symptoms with differential DX for which failure to recognize and treat can lead to serious and/or near-term morbidity.

• Member is not improving as expected, especially after two visits.

• MLP acknowledges uncertainty in management.

• Member demands to see supervising physician.

SPECIALIST REFERRALS

Referrals for specialist consultation and complex diagnostic procedures should reflect the personal diagnostic involvement of the MLP’s supervising physician, which should occur without unnecessary delays.

PATIENT RECORDS

The nurse practitioner will be responsible for the preparation of a complete medical record for each patient contact by entering all information into the patient’s electronic medical record. 7

EDUCATION AND TRAINING

The nurse practitioners must have the following:

• Possession of a valid California License as a Registered Nurse.

• Certification by the State of California, Board of Registered Nursing as a Nurse Practitioner.

• Possession of or ability to apply for a Furnishing number from the State of California, Board of Registered Nursing.

• Graduate of a Masters or Certified Program,

• National Certification of Appropriate Specialty for NP (eligibility)

• Continuing education to maintain license, national certification and stay current in their field.

SETTING

NPs can be utilized in the provision of primary care in the following clinical areas:

• Family Practice

• Pediatrics

• Obstetrics and Gynecology

• Immediate Care

• Other selected specialty areas (such as internal Medicine, Endocrinology, Geriatrics, etc.)

• Skilled Nursing Care Facilities

• Board and Care Facilities

• Outreach Services

• Disease Management

HEALTH CARE MANAGEMENT-PRIMARY CARE

POLICY

Primary care problems are common acute conditions such as pharyngitis, otitis media, vaginal infections, etc. OR chronic stable conditions such as hypertension, irritable bowel syndrome, oral contraceptive use, routine prenatal care, etc. The nurse practitioner is authorized to diagnose and treat primary care problems under the following protocol: PROTOCOL

1) A treatment plan is developed based on the resources listed in this document. 2) All other applicable Standardized Procedures in this document are followed during health care management.

3) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient Records, Supervision and Consultation in these Standardized Procedures are in force.

DATA BASE

Subjective: Chief complaint, history of present illness, pertinent past medial and surgical history.

Objective: General appearance, vital signs, and physical exam pertinent to chief complaint, pertinent laboratory and diagnostic tests.

TREATMENT PLAN

Assessment/diagnosis

1. Interim or final diagnosis most consistent with the subjective and objective findings. 2. Assessment of the status of the disease process when appropriate. TREATMENT

1. A treatment plan is developed based on resources listed in this document. 2. Further lab or diagnostic studies as appropriate. 3. Therapies as appropriate.

4. Diet and exercise as prescribed by the disease process and patient condition. 5. Patient/family education as appropriate to the disease process. FURNISHING MEDICATIONS

Following furnishing protocol utilizing the formulary. CONSULTATION

As describe in the General Policy component.

REFERRAL

DOCUMENTATION

Subjective and objective finding, assessment, and plan will be documented in the electronic medical record.

HEALTH CARE MANAGEMENT - SECONDARY CARE

POLICY

Secondary care conditions may be unfamiliar, uncommon, unstable or complex conditions such as severe abdominal pain, unstable sprain, vision loss, etc. The nurse practitioner is authorized to evaluate and treat Secondary Care conditions under the following protocol: PROTOCOL

1) A physician is communicated with regarding the evaluation, diagnosis and/or treatment plan.

2) Management of the patient is either in conjunction with a physician or by complete referral to a physician or secondary care treatment facility. 3) The physician is notified if her/his name is used on a referral to a specialty physician or department.

4) The consultation or referral is noted in the patient’s chart including name of physician. 5) All other applicable Standardized Procedures in this document are followed during health care management.

6) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient Records, Supervision and Consultation in these Standardized Procedures are in force. DATA BASE

Subjective: Chief complaint, history of present illness, pertinent past medical and surgical history, family and social history.

Objective: General appearance, vital signs, and physical exam pertinent to the chief complaint, pertinent laboratory and diagnostic test.

TREATMENT PLAN

Assessment/diagnosis

1. Interim or final diagnosis most consistent with the subjective and objective findings. 2. Assessment of status of the disease process when appropriate. TREATMENT

1. A treatment plan is developed based on the resources listed in this document. 2. Further laboratory or other diagnostic studies as appropriate. 3. Therapies when appropriate.

4. Diet and exercise prescription as indicated by the disease process and patient condition. 5. Patient/family education and counseling appropriate to the disease process. 6. A physician is contacted regarding evaluation, diagnosis, and or treatment plan. 11

7. Management of the patient is either in conjunction with a physician or by complete referral to a physician.

PHYSICIAN CONSULTATION

As described in the General Policy component.

REFERRAL

1. A referral should be made when conditions for which the diagnosis and/or treatment are beyond the scope of the nurse practitioner’s knowledge and/or skills, or for those conditions that require consultation.

2. The physician is notified if her/his name is used on a referral to a specialty physician or department.

3. The consultation or referral is noted in the patient’s record including the name of the physician.

FURNISHING MEDICATIONS

Follow furnishing protocol, utilizing the formulary. DOCUMENTATION

Subjective and objective finding, assessment, and plan will be documented in the electronic medical record.

HEALTH CARE MANAGEMENT-TERTIARY CARE

POLICY

Tertiary Care conditions are acute, life-threatening conditions such as respiratory arrest, major trauma, etc. The nurse practitioner is authorized to evaluate Tertiary Care conditions under the following protocol:

PROTOCOL

1) If a physician is not immediately available, initial evaluation and stabilization of the patient may be performed with concomitant notification of and immediate management by a physician or 911 Emergency Team as necessary. 2) The referral is noted in the patient’s chart including name of physician or agency, (e.g. ER), referred to.

3) All other applicable Standardized Procedures in this document are followed during health care management.

4) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient Records, Supervision and Consultation in these Standardized Procedures are in force. DATABASE

Subjective: Chief complaint, history of present illness, pertinent past medical and surgical history, family history, and social history.

Objective: General appearance, vital signs, physical exam pertinent to the chief complaint, and pertinent laboratory and diagnostic tests.

TREATMENT PLAN

Assessment/diagnosis

1. Interim or final diagnosis most consistent with the subjective and objective findings. 2. Assessment of status of the disease process when appropriate. TREATMENT

1. A treatment plan is developed based on the resources listed in this document. 2. A physician may perform initial evaluation and stabilization of the patient with concomitant notification of and immediate management. 3. Initial treatment may include notification of 911 Emergency Team. PHYSICIAN CONSULTATION

As described in the General Policy Component.

REFERRAL

FURNISING

Follow furnishing protocol, utilizing the formulary. DOCUMENTATION

Subjective and objective findings, assessment, and plan will be documented in the patient’s electronic medical record.

PROCEDURES AND MINOR SURGERY

POLICY

The nurse practitioner may perform the listed procedures under the following protocols: Abscess incision and drainage on non-facial area

Casting

Colposcopy and cryotherapy and cervical treatments Electrocautery of external lesions

Endometrial biopsy

Epidermal cyst removal on non-facial site

Focused transvaginal or abdominal ultrasound

Injection of subcutaneous local anesthesia

Insertion of chest tubes

Insertion of IV’s and venous cut downs’

Intrauterine or cervical inseminations

Intrauterine or cervical insemination

Intubation

IUD insertion and removal

Lumber punctures

Mole removal

Norplant insertions and removal

Office hysterscopy

Excision biopsy

Reduction of fractures and dislocation

Remove foreign body from eyes, ear and nose

Toe and finger nail removal

Wound care including repair of minor lacerations

PROTOCOLS

1) The nurse practitioner has been trained to perform the procedure(s) and has been observed satisfactorily performing the procedure(s) by another provider competent in that skill.

2) The nurse practitioner is following standard medical technique for the procedures as described in the resources listed in this document. 3) Physician consultation is obtained before casting is performed. 4) All moles and biopsied tissue are sent for a pathology report. 5) Appropriate patient consent is obtained before the procedure. 6) All other applicable Standardized Procedures in this document are followed during health care management.

7) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient Records, Supervision and Consultation in these Standardized Procedures are in force. DATABASE

Subjective: Chief complaint, history of present illness, pertinent past medical and surgical history, family history and social history.

Objective: General appearance, vital signs, and physical exam pertinent to chief complaint, procedure, or minor surgery.

TREATMENT PLAN

Assessment/diagnosis

1. Interim or final diagnosis most consistent with the subjective and objective findings. TREATMENT

1. The nurse practitioner is following standard medical technique for the procedures as described in the resources listed in this document. 2. All Patient/family education and counseling appropriate to the disease process, procedure, or minor surgery.

FURNISHING MEDICATION

Follow furnishing protocol, utilizing the formulary. PHYSICIAN CONSULTATION

As described in the General Policy Component.

REFERRAL

DOCUMENTATION

Subjective and objective findings, assessment, plan and the patient’s tolerance of the procedure will be documented in the patient’s electronic medical record. 16

HEALTH PROMOTION EXAMINATIONS

POLICY

Health promotion exams are periodic examinations of asymptomatic conditions such as immunizations, counseling, education, etc. The nurse practitioner is authorized to perform Health Promotion exams under the following protocol:

PROTOCOL

This protocol covers the periodic examination of chronic conditions and/or health promotion examinations for adult patients.

DATABASE

Subjective:

1. Information obtained from patient, or caregiver. 2. Patient, family caregiver concerns, history of present illness relating to concerns, past medical and surgical history, family history, social history, and review of symptoms.

Objective: General appearance, vital signs, physical exam, laboratory and diagnostic tests as appropriate.

TREATMENT PLAN

Diagnosis:

1. Interim or final diagnosis most consistent with the subjective and objective findings. If diagnosis is not clear, assessment to level of surety plus differential diagnosis.

2. Assessment of status of disease process when appropriate. 3. Assessment of health maintenance deficits, risk factors as appropriate. TREATMENT

1. Further laboratory or diagnostic studies as appropriate to age, history, and diagnosis.

2. Patient/family education and counseling on diet, exercise, self-screening for cancer.

3. Immunization update

4. Therapies when appropriate

PHYSICIAN CONSULTATION

As described in the General Policy Component.

REFERRAL

FURNISHING MEDICATIONS

Follow finishing protocol, utilizing the formulary. DOCUMENTATION:

Subjective and objective findings, assessment, and plan will be documented in the patient’s electronic medical record.

ORDERING LAB WORK/DIAGNOSTIC STUDIES

POLICY

The nurse practitioner is authorized to collect, order and interpret lab work and diagnostic studies under the following protocol:

PROTOCOL

1) Lab work and diagnostic studies obtained, such as CBC, chem. Panel, vaginal smears, urinalysis, throat cultures, basic imaging studies, etc. must be appropriate to Health Care Management as outlined in this document.

2) Advanced studies such as Thallium scans, MRI, etc. may also be obtained in conjunction with physician.

3) All other applicable standardized procedures in this document are followed during health care management.

4) All General Policies regarding Review, Approval, Setting, Education, Patient Records, Supervision and Consultation in these Standardized Procedures are in force. DATABASE

Subjective: Relevant history to warrant the need for the laboratory work or diagnostic study. Objective: Physical examination appropriate to warrant the need for the laboratory work or diagnostic study.

TREATMENT PLAN

Assessment/diagnosis

1. Subjective and objective findings consistent with the need for the laboratory work or diagnostic study.

TREATMENT

1. A treatment plan is developed based on the resources listed in this document. 2. Patient/family education and counseling as appropriate to the laboratory work or diagnostic study.

FURNISHING MEDICATIONS

Follow furnishing protocol, utilizing the formulary. PHYSICIAN CONSULTATION

Advanced studies such as CT scan, Thallium scans, and MRI may also be obtained in consultation with a physician.

REFERRAL

DOCUMENTATION

Subjective and objective findings, assessment and plan will be documented in the patient’s electronic medical record.

ORDERING THERAPIES

POLICIES

The nurse practitioner is authorized to order therapies such as occupational, speech and Physical therapy, and psychological counseling, under the following protocol: PROTOCOL

1) Therapies are ordered as part of a treatment plan implemented for Health Care Management as outlined in this document and consistent with Primary Care Physician preference.

2) All other applicable Standardized Procedures in this document are followed during health care management.

3) All General Policies regarding Review, Approval, Setting, Education, Evaluation, DATABASE

Subjective: Relevant history to warrant the need for the therapy. Objective: Physical exam appropriate to warrant the need for the therapy. TREATMENT PLAN

Assessment/diagnosis:

Subjective and objective information consistent with the need for the therapy. TREATMENT

1. A treatment plan is developed based on resources listed in this document. 2. Patient/family education and counseling appropriate to the need for the therapy. FURNISHING MEDICATIONS

Follow furnishing protocol, utilizing the formulary. REFERRAL

A referral should be made when conditions for which the diagnosis and/or treatment are beyond the scope of the nurse practitioner’s knowledge and/or skills, or for those conditions that require consultation; with concurrence of the supervising physician and/or Primary Care Physician. DOCUMENTATION

Subjective and objective findings, assessment, and plan will be documented in the patient’s electronic medical record regarding the need for the therapy. 21

DISPENSING MEDICATIONS

POLICY

The nurse practitioner may dispense prescription drugs and devices under the following protocols:

PROTOCOLS

1) The drugs or devices are under a valid prescription from a person lawfully authorized to prescribe, including the nurse practitioner that is transmitting an order based on the Standardized Procedures in this document.

2) The drug or device is being used in and FDA fashion. Non-FDA approved orders for prescriptions must have physician approval.

3) Appropriate patient education regarding the drug and/or device is given. 4) The drug or device is labeled pursuant to the Business and Professions Code (see Appendix IV: Container Labeling Requirements)

5) All appropriate record keeping practices of the dispensary are performed. 6) All other applicable Standardized Procedures in this document are followed during health care management.

7) All General Policies regarding Review, Approval, Setting, Education, Evaluation, Patient Records, Supervision and Consultation in these Standardized Procedures are in force. DATABASE

No contraindications from patient history.

No contraindications from physical exam and lab findings. TREATMENT PLAN

Assessment/diagnosis

1. Subjective and objective information consistent with the use of the medication with no absolute contraindications to the use.

TREATMENT

Medications dispensed to be labeled with:

1. Name of medication

2. Dose of medication

3. Quantity of dispensed medication

4. Directions for use

5. Expiration date

6. Patient’s name

7. Dispensers initials

Provide patient with information including directions for taking drug, what to do and whom to contact if side effects occur, possible serious or harmful effects or the drug. PHYSICIAN CONSULTATION

As stated under the General Policy Component.

DOCUMENTATION

Document in the electronic medical record, the name, route and amount of medication. 23

MEDICATION MANAGEMENT

POLICY

The nurse practitioner may independently initiate the oral transmission of a valid prescription order under the following protocol:

PROTOCOL

1) All the drugs and devices ordered are per the recommendations in the resources listed in this documented.

2) The ordering of drugs or devices includes the initiation, discontinuation and/or renewal of prescriptive medications and/or their over-the-counter equivalents. 3) Medication history has been obtained:

• Other medications being taken.

• Medication allergies and contraindications.

• Prior medications used for current conditions.

4) The drug or device is appropriate to the condition being treated:

• Lowest dosage effective per pharmaceutical references.

• Not to exceed upper limit dosage per pharmaceutical references.

• Generic medications are ordered if appropriate.

DATABASE

Subjective:

1. Relevant history including current medications. 2. Allergy history.

3. Personal or family history, which is contraindication to the use of the medication. Objective:

1. Physical exam appropriate to warrant the use of the medication. 2. Lab tests to indicate/contraindicate use of the medication. TREATMENT PLAN

Assessment/diagnosis

Subjective and objective information consistent with the use of the medication with no absolute contraindications to the use.

TREATMENT

All the medications ordered are per the recommendations in the resources listed in this document and/or by the Primary Care Physician’s preference. The medication is appropriate to the condition being treated. 24

FURNISHING MEDICATIONS

Follow furnishing protocol utilizing the formulary. PHYSICIAN CONSULTATION

Consultation with a physician is noted in the patient’s medical record, including the physician’s name.

As described in the General Policy Component.

REFERRAL

A referral should be made for non-responsiveness to appropriate therapy and/or unusual or unexpected side effects.

DOCUMENTATION

A plan for follow-up and refills is written in the patient’s electronic medical record. The prescription must be documented in the patient’s electronic medical record including name of the drug strength, and quantity, and signature of the Nurse Practitioner. 25

FURNISHING DRUGS and DEVICES

POLICY

The nurse practitioner may order, or write a transmittal order for, drugs or devices pursuant to sections 2725 and 2836.1-1836.3 (Appendix III) of the Business and Professions Code and under the following protocols:

PROTOCOLS

1) The furnishing number must be acquired from the State of California, Board of Registered Nursing.

2) The drugs and/or devices are either:

- Incidental to family planning

- Incidental to pre-natal care

- Incidental to the provision of routine health care rendered to essentially healthy persons.

3) The drug or device being furnished as part of a treatment plan implemented for disease management as outlined in the document.

4) The drug or device is being used in and FDA approved fashion. Non-FDA approved orders for prescription drugs must be made in consultation with a

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