Running head: STANDARD CARE ARRANGEMENT

Standard Care Arrangement

Melanie Garner
Wright State University Miami Valley
College of Nursing and Health

STANDARD CARE ARRANGEMENT

Standard Care Arrangement

Premier Health Partners: Standard Care Arrangement of the Advanced Practice
Registered Nurse
The standard care arrangement (SCA), as defined by the Ohio Revised Code (ORC)
4723.01, is a written, formal guide for planning and evaluating a patients health care that is
developed by one or more collaborating physicians and the certified nurse practitioner (CNP)
and meets the requirements of Section 4723.431 of the ORC and Rules adopted by the Ohio
Board of Nursing.
Prior to engaging in practice, a SCA must be entered into with each physician with whom
the CNP collaborates and whose practice is the same or similar to the nurses nursing specialty
(ORC 4723.44). The SCA will be revised to reflect the addition or deletion of a physician with
whom the nurse collaborates within that employment setting. The SCA shall include the
signatures of the CNP and each collaborating physician with whom the CNP primarily
collaborates indicating review of and agreement to abide by the terms of the SCA. The most
current copy of the SCA shall be retained and be available upon request of the Ohio Board of
Nursing at each practice site.
The CNP that a physician has entered into a SCA with must be continuously available to
communicate with the CNP either in person, or by telephone or other form of
telecommunication. A hospital that negotiates a SCA shall develop the SCA in accordance with
Section 4723.431 of the ORC and Rules adopted by the Ohio Board of Nursing. Review and
approval of the SCA shall be in accordance with the policies and procedures of the hospital
governing body and the bylaws, policies, and procedures of the hospital medical staff. The SCA

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is not an employment contract and does not alter or change the employment at will status of the
CNP.
Section I: Statement of Services
The CNP shall provide to individuals and groups nursing care that requires knowledge
and skill obtained from advanced formal education and clinical experience. The CNP shall
practice in accordance with the advanced practice nurses (APN) specialty, education, national
certification, Chapter 4723 of the ORC, and Rules adopted by the Ohio Board of Nursing. The
CNP activities may include direct patient care and/or management, education, research, and
consultation.
The CNP who holds a valid Certificate to Prescribe (CtP) [including a CtP-Externship
(CtP-E)], may prescribe drugs and therapeutic devices in accordance with Sections 4723.38
through 4723.50 of the ORC, the Rules of the Ohio Board of Nursing, and within the formulary
made available by the Ohio Board of Nursing (see Section VII of this SCA). This SCA permits a
CNP to supervise services provided by a home health agency as defined in Section 3701.881 of
the ORC. The CNP may provide preventative and primary care services and evaluate and
promote patient wellness.
Section II: Incorporation of New Technology or Procedures
Consistent with the CNP scope of practice (ORC 4723.43 and Rules adopted by the Ohio
Board of Nursing), the CNP will identify new technology/new procedures needed in his/her
clinical practice. The CNP will maintain documentation as evidence to show knowledge, skills,
and abilities to perform the procedure or activity. The following will be utilized to meet this
requirement: APN education programs, such as continuing education events, workshops, and

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conferences; a preceptorship, fellowship, or internship; and/or other formally organized

educational experiences.
Section III: Quality Assurance Provisions
Periodic review and reapproval of the SCA.
The SCA shall be reviewed and re-signed every two years. Each APN who is a party to
the arrangement and at least one collaborating physician shall sign and date the biennial review
of the SCA.
Criteria for referral of a patient by the CNP to a collaborating physician.
The CNP will refer a patient to the collaborating physician as the CNP considers
clinically appropriate including, without limitation, in the following circumstances: a request
from a patient to see the collaborating physician; a patient whose clinical condition is unusual,
who is not making satisfactory progress, or whose condition is unresponsive to the plan of care; a
patient with a complicated diagnosis and/or multi-faceted treatment outside of parameters
established by the CNP and the collaborating physician; and any other reason as determined by
the CNP and/or the collaborating physician.
Process for the CNP to obtain a consultation with a collaborating physician.
For the purpose of this section, consultation means the discussion or communication
between the CNP and a physician. The CNP will determine the need for a consultation and
contact (via direct verbal or electronic communication) the collaborating physician to obtain the
consultation.
Procedure for regular review of referrals made by the CNP to other health care
professionals and the care outcomes for a representative sample of all clients seen by
the CNP.

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At the annual or semi-annual chart review process, the collaborating physician will
review the referrals of the CNP to other health care professionals and the care outcomes for a
representative sample of all clients seen by the CNP.
CNP participation in the quality assurance process through a chart review in
accordance with Rule 4723-8-04 and 4723-8-05 of the Ohio Administrative Code
(OAC).
A periodic random chart review will occur at least annually by the CNP and a
collaborating physician or a designated member of a quality assurance committee, composed of
at least one physician, of the institution, organization, or agency where the nurse practices. A
review of prescriptions written and the prescribing patterns for CtP/CtP-E holders will occur at
least semi-annually, including a representative of schedule II prescriptions.
Subsequent to each chart review, a conference shall be held between a collaborating
physician or a designated member of a quality assurance committee, composed of at least one
physician, of the institution, organization, or agency and the CNP to maintain or improve care
delivery. Such conference shall be documented and include, but not be limited to: a discussion
of the results of the chart review; identification of client care issues; a process for client
evaluation of care, a plan whereby results of the chart review and conference are to be used to
maintain or improve care delivery; and, where applicable, whether past plans for improving care
delivery have been effectively implemented.
Biennial licensure verification (OAC 4723-8-05).
Every two years, the CNP shall verify the licensure and, if applicable, certification status
of each collaborating physician with whom the nurse has a SCA. Verification of license status

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may be provided by an employing institution, organization, medical group practice, or agency

and may be obtained online from Ohio e-license center.
Section IV: Plan for Coverage of Patients in Instances of Emergency or Planned Absences
of Either the CNP or the Collaborating Physician
In the event of a planned or unplanned absence by the CNP, scheduled patients will be
seen by another CNP or by a collaborating physician. If the event of a planned or unplanned
absence of the collaborating physician, the nurse will be notified and the collaborating physician
will designate a physician colleague to cover in his or her absence.
Section V: Process for Resolution of Disagreements Regarding Matters or Patient
Management
Should a disagreement arise between the CNP and the collaborating physician regarding
diagnosis, treatment, or any other aspect of patient care and/or management, one or more of the
following means for resolution shall be followed: consult with an uninvolved physician or CNP
colleague within the clinical department, refer to current professional literature appropriate to the
area in question, or consult with a specialist in the area of question. Appropriate institutional
chain-of-command processes will be adhered to as necessary or required. In the event that a
clinical agreement is still not reached after following the above steps, the department medical
director will arbitrate. If the disagreement is between the CNP and the medical director, the chief
of staff (or medical director) will make the final decision.
Section VI: Arrangement Regarding Reimbursement
Current state and federal laws governing reimbursement and billing will be adhered to
including those under the medical assistance program as set forth in division C of section
5111.02 of the ORC and in accordance with any Rules adopted under division B of section

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5111.02 of the ORC. In accordance with 4723.28 ORC, the CNP is prohibited from waiving the
payment of all or any part of a deductible or copayment (or advertising as such) that a patient,
pursuant to a health insurance or health care policy, contract, or plan that covers such nursing
services, would otherwise be required to pay if the waiver is used as an enticement to a patient or
group of patients to receive health care services from that provider.
Section VII: Scope of Prescriptive Practice
For the purpose of this section consultation means the discussion or communication
between a nurse holding a current valid CtP/CtP-E with a collaborating physician prior to
initiating the prescription of a drug. The consultation relative to drug therapy shall be
documented in the patients record and shall include the consulting physicians name and the date
the consultation took place. The CNP who holds a valid CtP (including CtP-E) may prescribe
drugs and therapeutic devices and personally furnish samples and stock medication in
accordance with sections 4723.48 through 4723.50 of the ORC, the Rules of the Ohio Board of
Nursing, and within the Formulary made available by the Ohio Board of Nursing. In accordance
with ORC 4723.481, the nurses prescriptive authority shall not exceed that of the collaborating
physician.
The CNP who wishes to prescribe controlled substances will obtain prior approval
through the United States Drug Enforcement Agency. The CNP who holds a valid CtP
(including CtP-E) will comply with the provisions for prescribing opioids to minors in
accordance with section 3719.061 of the ORC. The prescribing CNP shall comply with
conditions of prescribing a drug that is either an opioid analgesic or a benzodiazepine in
accordance with ORC section 4723.487 and OAC section 4723-9-12. The CNP shall not
prescribe any drug or device to perform or induce abortion (ORC 4723.44 and OAC 4723-9-09).

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In accordance with 4723.431 ORC, a physician shall not collaborate with more than three
CNP prescribers at the same time (this does not apply to the CNP who does not hold a CtP/CtPE). A nurse who holds a current valid CtP/CtP-E shall prescribe in a valid prescriber-patient
relationship (OAC 4723-9-09). Except in an emergency situation, a nurse holding a current,
valid CtP/CtP-E shall not prescribe for a family member or other individual for whom the nurses
personal or emotional involvement may render the nurse unable to exercise detached
professional judgement in making diagnostic or therapeutic decisions (OAC 4723-9-09).
The CNP will prescribe from the most recent version of the Formulary approved by the
Committee on Prescriptive Governance (CPG) available on the Ohio Board of Nursing website:
www.nursing.ohio.gov. The CNP may also prescribe newly FDA-approved drugs not yet
reviewed and approved by the CPG, unless later disapproved by the CPG, if: the ability to
prescribe the drug is within the APNs scope of practice; the drug type or subtype is included on
the formulary as one that may be prescribed, or may be prescribed according to the APNs SCA;
and the collaborating physician has agreed in the SCA that the nurse may prescribe drugs
approved by the FDA, that meet the criteria set forth as described previously and that have not
yet been reviewed and approved by the CPG.
Signatures of the CNP and the collaborating physician imply acceptance of the Formulary
as written. Any restrictions to selected drugs or therapeutic devices within the Formulary, as
agreed upon by the CNP and the physician, shall be indicated in the Addendum to this SCA.
Provisions to ensure timely direct, personal evaluation of the patient by the
physician or a physician designee.
The collaborating physician, or a physician designee, will be available to personally
evaluate the patient in a timely manner relative to the patients condition.

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Provisions for use of drugs with non-Food and Drug Administration (FDA)
approved indications.
The CNP may prescribe drugs and therapeutic devices for off-label use (not an approved
FDA label indication) if the following criteria are met: the off-label indication(s) must be
consistent with the CNP scope of practice and the practice specialty of the collaborating
physician; the prescribing is in accordance with provisions of the established formulary; the offlabel drug and indication(s) are included in the attached, dated SCA Addendum; and the off-label
indication(s) is/are supported by current peer reviewed literature.
Provisions for use of drugs approved by the FDA and approved by the CPG
subsequent to the date of the SCA.
All drugs and therapeutic devices approved by the FDA and reviewed by the CPG
subsequent to either the date of the initial execution or the most recent review of this SCA shall
follow the Formulary guidelines of prescribing and this SCA, and must be consistent with the
CNPs scope of practice and the practice specialty of the collaborating physician.
Provisions for drugs previously reviewed by the CPG but approved by the FDA for
new indications subsequent to the date of the SCA.
All drugs and therapeutic devices approved by the FDA for a new indication and
reviewed by the CPG subsequent to either the date of the initial execution or the most recent
review of this SCA shall follow the Formulary guidelines of prescribing, this SCA, and must be
consistent with the CNPs scope of practice and the practice specialty of the collaborating
physician.
Procedure for prescription review.

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The CNP should have a procedure with the collaborating physician or designated member
of a quality assurance committee, composed of at least one physician, of the institution,
organization, or agency where the nurse has practiced during the period covered by the review, to
conduct a periodic review, at least semi-annually, of a representative sample of prescriptions
(including schedule II prescriptions) written by the nurse. This review may be completed as part
of the quality assurance review described above in Section III.
Standards and procedures for the appropriate conduct of a CtP-E as described in
section 4723.484 of the ORC.
The CtP-E means the practice relationship between a nurse who holds a current, valid
externship CtP and one or more licensed physicians during which time the nurses prescribing
activities are reviewed and evaluated by a supervising professional for the purpose of ongoing
improvement of the nurses competence, knowledge, and skill in pharmacokinetic principles and
the application of these principles to the nurses area of practice (OAC 4723-9-04).
For the CNP who holds a valid authority to prescribe drugs and therapeutic devices in
another jurisdiction, the externship requirement may be waived or reduced by the Ohio Board of
Nursing if the CNP meets the documentation and other requirements in accordance with sections
4723.48 and 4723.482 of the ORC and 4723-9-04 OAC. The externship period shall be
consistent with ORC 4723.484 and Rules adopted by the Ohio Board of Nursing and shall
consist of not less than 1,500 and not more than 1,800 hours during which the nurses prescribing
practices shall be supervised as follows: for a minimum of 500 hours, direct supervision, as
defined in paragraph K1 of the OAC 4723-9-01, shall be provided by a supervising professional.
A CNP who holds a CtP (not a CtP-E) may supervise no more than 200 of the 500 hours of
supervision; for the remaining hours, indirect supervision, as defined in paragraph K2 of the

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OAC 4723-9-01, shall be provided by a physician; and the externship CtP is valid for one year
and may be extended for an additional year if the nurse submits evidence satisfactory to the Ohio
Board of Nursing of continued participation in an externship as set forth in Rule 4723-9-04 and
4723-9-05 of the OAC.
For the purpose of this section, direct supervision means the supervising professional is
available on site and indirect supervision means the timely review by a physician of prescriptions
written by and prescribing practices of a nurse holding an externship certificate to prescribe
(OAC 4723-9-01).
The CNP and the supervising physician must make timely chart reviews of the patients
treated and prescriptions written by the nurse. The SCA shall specify the frequency of the review
needed for appropriate oversight. The manner in which supervision must be provided may vary
according to the location where the nurse is practicing and with the nurses level of experience.
The following standards and procedures will be used in evaluating a nurses participation in an
externship: a periodic, random chart review to include a review of prescriptions written and the
prescribing patterns will occur at least monthly by the CNP and a collaborating physician, and
subsequent to each chart review, a conference shall be held between a collaborating physician
and the CNP. This conference shall be documented and include, but not be limited to: a
discussion of the results of the chart review, identification of client care and/or prescribing
issues, a process for client evaluation of care, a plan whereby results of the chart review and
conference are to be used to maintain or improve care delivery, and where applicable, whether
past plans for improving care delivery have been effectively implemented.
Section VIII: SCA Addendum
Please refer to the SCA Addendum 1.

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Section IX: Other Additions

The CNP in collaboration with the physician may provide any additional limitations,
guidelines, or parameters in this SCA (not to exceed, but within the limits of Chapter 4723 of the
ORC and Rules adopted by the Ohio Board of Nursing). These may include clinical practice
guidelines, standards of practice, scope of practice, and position statements published by
nationally certifying bodies and professional associations and/or the Ohio State Board of
Pharmacy Ohio Automated Rx Reporting System (OARRS), a prescription monitoring program
that tracks all controlled substances (to include, tramadol and carisoprodol) dispensed to an
outpatient (OAC 4729-17-01).

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Section X: Standard Care Arrangement Signature Page

Pursuant to ORC Section 4723.431, the undersigned have reviewed and agreed to the
terms and conditions of this Standard Care Arrangement. This Standard Care Arrangement
contains all the necessary provisions, required by law, and any changes or amendments to the
Standard Care Arrangement must be agreed to by the undersigned, in writing, and incorporated
as part of the Standard Care Arrangement.
CNP
Name________________________________________________________________________
Specialty__________________________________________Practice Area_________________
Address_______________________________________________________________________
Phone (W)__________________Phone (C)__________________Phone (H)________________
Signature___________________________________________________Date_______________

Collaborating Physician (s) or Designated Power of Attorney

Name________________________________________________________________________
Specialty__________________________________________Practice Area_________________
Address_______________________________________________________________________
Phone (W)__________________Phone (C)__________________Phone (H)________________
Signature___________________________________________________Date_______________
Each Independent Practice Group must designate a Collaborating Physician (s) or Designated
Power of Attorney. Information must be provided as above OR if you collaborate with multiple
physicians please utilize the Power of Attorney Standard Care Arrangements form and signature
page.