You can develop a new protocol or use this one and reduce similarities less 5%

ARNPProtocol – (format example does not have to be followed in total or in part)

The ARNP and supervising physician determine the content of the protocol agreement.

I. Requiring Authority:
A. Nurse Practice Act, Chapter 464, Florida Statutes

B. Chapter 64B9 4, Florida Administrative Code, Rules Pertaining to Advanced Registered Nurse Practitioners

II. Parties to Protocol:

(Should include: name, address, ARNP certificate number, and DEA number of the ARNP (if applicable); name, address,

license number, and DEA number of all supervising physicians or dentists; Nature of practice, practice location, including

primary and satellite sites)

A. (Name), ARNP, ARNP 9999999, DEA 999999 (If applicable)

ARNP Address

123 Street

Anywhere, FL 12345

B. (Name of authorized supervising physician), title, Florida license number, DEA 999999

Physician Address

456 Avenue

Anywhere, FL 12345

C. Practice Name

Practice Location

123 Main Street

Somewhere, FL 99999

III. Nature of the Practice

This collaborative agreement is to establish and maintain a practice model in which the ARNP will provide health care

services under the general supervision of (name of authorized supervising physician, title). This practice shall encompass

family practice and shall focus on health screening and supervision, wellness and health education and counseling, and the

treatment of common health problems. [Use appropriate description for your specialty and activities; practice location(s)]

IV. Description of the duties and management areas for which the ARNP is responsible:
A. Duties of the ARNP:

The ARNP may interview clients, obtain and record health histories, perform physical and development

assessments, order appropriate diagnostic tests, diagnose health problems, manage the health care of those

clients for which the ARNP has been educated, provide health teaching and counseling, initiate referrals, and

maintain health records. (Specific guidelines for patient care decision making may be referenced here. I.e., ARNP

developed practice guidelines, professionally developed guidelines, text books, etc. Do not send these references

to the Board of Nursing.)

B. The conditions for which the ARNP may initiate treatment include, but are not limited to:

Otitis media and externa

Conjunctivitis

Upper respiratory tract infections Sinusitis

Infections Sinusitis

C. Treatments that may be initiated by the ARNP, depending on the patient condition and judgment of the ARNP:

Suture of simple and complex lacerations not requiring ligament or tendon repair.

Incision and drainage of abscesses.

Removal of ingrown toenail

ARNP Protocol – (format example does not have to be followed in total or in part)
The ARNP and supervising physician determine the content of the protocol agreement.

D. Drug therapies that the ARNP may prescribe, initiate, monitor, alter, or order

ARNPs can prescribe or dispense a controlled substance as defined in Section 893.03, Florida Statutes, if the ARNP

graduated from a program with a master’s or doctoral degree in a clinical nursing specialty area with training in

specialized practitioner skills (authority granted by law on January 1, 2017).

V. Duties of the Physician

The physician shall provide general supervision for routine health care and management of common health problems, and

provide consultation and/or accept referrals for complex health problems. The physician shall be available by telephone or

by other communication device when not physically available on the premises. If the physician is not available, his

associate, (Name of Backup Physician), title, Florida license number/DEA #999999 (or other description of designated

authorized supervising physician), will serve as backup for consultation, collaboration and/or referral purposes.

VI. Specific Conditions and Requirements for Direct Evaluation
With respect to specific conditions and procedures that require direct evaluation, collaboration, and/or consultation by the

physician, the following will serve as a reference guide:

Clinical Guidelines in Family Practice, X Edition, by Constance R. Uphold, ARNP, PhD, and Mary Virginia Graham, ARNP, PhD

(or other reference text or practitioner created reference guide)

OR

The physician will be consulted for the following conditions:

3rd degree lacerations

Severe hypertension determined by _

Etc. (list appropriate conditions)

VII. All parties to this agreement share equally in the responsibility for reviewing treatment protocols as needed.
(At practice locations where multiple physicians or dentists are supervising the same ARNPs, the practice may delegate to one of the

supervising physicians or dentists the authority to sign the protocol for the physicians or dentists listed on the protocol)

Signature /

(Printed Name), ARNP Date

Signature /

(Printed Name), Title Date

PLEASE NOTE:

Effective June 23, 2017, under HB453, in accordance with 464.012 Florida Statutes, practicing ARNPs must maintain their protocol

onsite at their place of employment. The Board of Nursing will no longer be required to receive, review, or maintain Advanced

Registered Nurse Practitioner protocols.

464.012(3), F.S. An advanced registered nurse practitioner shall perform those functions authorized in this section within the

framework of an established protocol which must be maintained onsite at the location or locations at which an advanced registered

nurse practitioner practices. In the case of multiple supervising physicians in the same group, an advanced registered nurse

practitioner must enter into a supervisory protocol with at least one physician within the physician group practice.

The supervising physician is responsible for submitting a notice to the Board of Medicine that they have entered into a supervisory

relationship with an ARNP.