TITLE68:PROFESSIONSANDOCCUPATIONS

CHAPTERVII:DEPARTMENTOFFINANCIALANDPROFESSIONALREGULATION
SUBCHAPTERb:PROFESSIONSANDOCCUPATIONS
PART1300NURSEPRACTICEACT
SECTION1300.EXHIBITASAMPLEWRITTENCOLLABORATIVEAGREEMENT

Section1300.EXHIBITASampleWrittenCollaborativeAgreement

ADVANCEDPRACTICENURSING
WRITTENCOLLABORATIVEAGREEMENT

A.
ADVANCEDPRACTICENURSEINFORMATION
1.

9.

NAME:
ILLINOISRNLICENSE
NUMBER:

ILLINOISAPN
LICENSENUMBER:

ILLINOISMIDLEVELPRACTITIONERLICENSE
NUMBER:
FEDERALMIDLEVELPRACTITIONERDEA
NUMBER:

AREASOF
CERTIFICATION:

CERTIFYING
ORGANIZATION:

CERTIFICATION
EXPIRATIONDATE:

CERTIFICATION
NUMBER:

PRACTICESITES:
(AttachListofSites)

CONTACT
NUMBER:

FACSIMILE
NUMBER:

EMERGENCY
CONTACTNUMBERS:

(e.g.,pager,answering
service)

ATTACHMENTS:

Copyof
Certification/Recertification
CopiesofRN&APN
License
CopyofCertificateof
Insurance
CopyofMidLevel
PractitionerLicense

2.

3.
4.
5.
6.
7.
8.

B.

COLLABORATINGPHYSICIAN/PODIATRIST/DENTISTINFORMATION

1.

C.

NAME:

ILLINOISLICENSE
2.
NUMBER:

PRACTICEAREAOR
3.
CONCENTRATION:

BOARD
CERTIFICATION(if
4.
any):

CERTIFYING
5.
ORGANIZATION:

PRACTICESITES:(Attach
6.
ListofSites)

CONTACT
7.
NUMBER:

FACSIMILE
NUMBER:

EMERGENCYCONTACT
NUMBERS:
(e.g.,pager,answering

service)
ADVANCEDPRACTICENURSECOLLABORATINGPHYSICIAN/PODIATRIST/
DENTISTWORKINGRELATIONSHIP
1.

WRITTENCOLLABORATIVEAGREEMENTREQUIREMENT

AwrittencollaborativeagreementisrequiredforallAdvancedPracticeNurses
(APNs)engagedinclinicalpracticeoutsideofahospitalorambulatorysurgical
treatmentcenter(ASTC).AnAPNmayprovideservicesinalicensedhospitalor
ASTCwithoutawrittencollaborativeagreementordelegatedprescriptive
authority.

2.

SCOPEOFPRACTICE

Underthisagreement,theadvancedpracticenursewillworkwiththe
collaboratingphysicianorpodiatristinanactivepracticetodeliverhealthcare
servicesto_______________.Thisincludes,butisnotlimitedto,advanced
nursingpatientassessmentanddiagnosis,orderingdiagnosticandtherapeutic
testsandprocedures,performingthosetestsandprocedureswhenusinghealth
careequipment,interpretingandusingtheresultsofdiagnosticandtherapeutic
testsandproceduresorderedbytheAPNoranotherhealthcareprofessional,
orderingtreatments,orderingorapplyingappropriatemedicaldevices,using
nursing,medical,therapeuticandcorrectivemeasurestotreatillnessandimprove
healthstatus,providingpalliativeandendoflifecare,providingadvanced
counseling,patienteducation,healtheducationandpatientadvocacy,prescriptive
authority,anddelegatingnursingactivitiesortaskstoaLPN,RNorother
personnel.
Ifapplicable,theadvancedpracticenurseshallmaintainalliedhealthpersonnel
privilegesatthefollowinghospitalsforthedesignatedservices:
Hospitals:

Thiswrittencollaborativeagreementshallbereviewedandupdatedannually.A
copyofthiswrittencollaborativeagreementshallremainonfileatallsiteswhere
theadvancedpracticenurserendersserviceandshallbeprovidedtotheIllinois
DepartmentofFinancialandProfessionalRegulationuponrequest.Anyjoint

ordersorguidelinesaresetforthorreferencedinanattacheddocument.

3.

COLLABORATIONANDCONSULTATION
Collaborationandconsultationshallbeadequateifthecollaborating
physician/podiatrist:

(A)
participates in the joint formulation and joint approval of orders or
guidelines with the advanced practice nurse, as needed based on the
practice of the practitioners, and periodically reviews those orders and
the services provided patients under those orders in accordance with
accepted standards of medical practice and advanced practice nursing
practice

(B)
meetsinpersonwiththeAPNatleastonceamonthtoprovide
collaborationandconsultationand

(C)
isavailableinperson,orthroughtelecommunications,forconsultation
andcollaborationonmedicalproblems,complicationsoremergencies
orforpatientreferral.(See225ILCS60/54.5(b)(5).)

Thewrittencollaborativeagreementshallbeforservicesthecollaborating
physicianorpodiatristgenerallyprovidestohisorherpatientsinthenormal
courseofclinicalpractice.
InformationspecifictocollaborationandconsultationwithaCRNAisas
follows:
(A)
AlicensedCRNAmayprovideanesthesiaservicespursuanttotheorder
ofalicensedphysician,podiatristordentist.

(B)
Foranesthesiaservices,ananesthesiologist,physician,podiatristor
dentistparticipatesthroughdiscussionofandagreementwiththe
anesthesiaplanandisphysicallypresentandavailableonthepremises
duringthedeliveryofanesthesiaservicesfordiagnosis,consultationand
treatmentofemergencymedicalconditions.

(C)
ACRNAmayselect,orderandadministermedications,including
controlledsubstances,andapplyappropriatemedicaldevicesfor
deliveryofanesthesiaservicesundertheanesthesiaplanagreedtobyan
anesthesiologist,ortheoperatingphysician,operatingpodiatristor
operatingdentist.(See225ILCS65/6535(c5)and(c10).)

(D)
Inaphysician'soffice,theCRNAmayonlyprovideanesthesiaservices
ifthephysicianhastrainingandexperienceinthedeliveryofanesthesia
servicestopatients.

(E)
Inapodiatrist'soffice,theCRNAmayonlyprovidethoseservicesthe
podiatristisauthorizedtoprovidepursuanttothePodiatricMedical
PracticeAct.

(F)
AcollaborativeagreementbetweenaCRNAandadentistmustbein
accordancewith225ILCS65/6535(c10).Inadentist'soffice,the
CRNAmayonlyprovidethoseservicesthedentistisauthorizedto
providepursuanttotheIllinoisDentalPracticeAct.

4.

COMMUNICATION,CONSULTATIONANDREFERRAL
Theadvancedpracticenurseshallconsultwiththecollaborating
physician/podiatristbytelecommunicationorinpersonasneeded.Intheabsence
ofthedesignatedcollaboratingphysician/podiatrist,anotherphysician/podiatrist
shallbeavailableforconsultation.

5.

Theadvancedpracticenurseshallinformeachcollaboratingphysician/podiatrist
ofallwrittencollaborativeagreementsheorshehassignedwithother
physicians/podiatrists,andprovideacopyofthesetoanycollaborating
physician/podiatristuponrequest.

DELEGATIONOFPRESCRIPTIVEAUTHORITY
Asthecollaboratingphysician/podiatrist,anyprescriptiveauthoritydelegatedto
theadvancedpracticenurseissetforthinanattacheddocument.

NOTE:ADVANCEDPRACTICENURSEMAYONLYPRESCRIBE
CONTROLLEDSUBSTANCESUPONRECEIPTOFANILLINOISMID
LEVELPRACTITIONERCONTROLLEDSUBSTANCESLICENSE.

WETHEUNDERSIGNEDAGREETOTHETERMSANDCONDITIONSOFTHIS
WRITTENCOLLABORATIVEAGREEMENT.

Collaborating
Physician/Podiatrist/Dentist
Signature/Date

AdvancedPracticeNurse
Signature/Date

(Physician's/Podiatrist's/Dentist's
TypedName)

(AdvancedPracticeNurse'sTypedName)