background and definitions

Template for Standardized Protocol and Procedures Physician Assistants

INSTRUCTIONS:

This template has been designed to minimize your time and effort in submitting your standardized protocol and procedure(s) as part of your credentialing application with the Medical Staff Office.

You are responsible for the contents of this document so please read it carefully before submitting.

All text in this document in blue and underlined must be replaced with information that is specific to your practice and procedure(s). Please leave the information that you have added in blue and underlined.

Do NOT edit or delete any of the other text or formatting in this document that is not blue, bolded and underlined.

Do NOT change anything in the footer of the document.

document.docCIDP Approval:Credentials Approval:EMB/GAC Approval:Future Review Due: At recredentialing

Standardized Protocol and Procedures for Assessment and Management of Acute

and Chronic Patients:SPECIFY PRACTICE/PROTOCOL NAME

Check all that apply (double-click on a gray box below to select “Checked” button):

Adults Pediatrics Both Adults & Pediatrics

Inpatient Clinical Setting Outpatient Clinical Setting Both Inpatient & Outpatient Clinical Setting

PART ISTANDARDIZED PRACTICE PROTOCOL

PHYSICIAN ASSISTANT

I. Background and Definitions

A. Development

1. This Standardized Protocol and Procedures for implementation at UCSF Medical Center and Children’s Hospital was developed under the direction of the Committee on Interdisciplinary Practice (CIDP), the Executive Medical Board (EMB), Legal name of Physician Assistant, degree(s) and credentials, and Physician and Department.

2. Practice-specific job descriptions have been developed collaboratively by: Names of the Medical Director and the Physician Assistant of the Name of Department.The named Physician Assistant is authorized to provide care under this Standardized Protocol and Procedures. Should additional Physician Assistants be authorized to provide care under this document, it will be amended to include those names. Additional names will only be added after credentials are reviewed by the Credentials Committee, Executive Medical Board and Governance Advisory Council.

3. The increasingly acute nature of the populations cared for under this Standardized Protocol and Procedures calls for greater specificity in their content. In order to ensure their continued appropriateness, this will be reviewed every two years by CIDP, the Medical Director and the Physician Assistant working under this Standardized Protocol and Procedures, or sooner if substantial changes are made to the practice outlined here. Both the Physician Assistant and his/her supervising physician are responsible for notifying CIDP of such changes when they occur.

B. Scope and Setting of Practice

1. Physician Assistants may perform the following delegated functions as appropriate to their scope of practice:

document.docCIDP Approval: Credentials Approval:EMB/GAC Approval: Page 1Future Review Due: At re-credentialing

Standardized Protocol for Assessment and Management of Acute and Chronic Patients: SPECIFY PRACTICE/PROTOCOL NAME

a. Routine management of chronic stable medical conditions and minor acute care according to approved protocols.

b. Medical and surgical procedures according to approved standardized procedures.

2. Physician Assistants will work under the supervision of Name of Supervising Physician of the Name of Department.

3. In addition to general consultation, immediate physician consultation will be obtained under the following circumstances from Name of Supervising Physician, or his/her designee:

a. Exacerbation of symptoms after initial treatment;

b. Acute decompensation or deterioration of patient status, including respiratory distress, change in level of consciousness, or evidence of cardiovascular compromise;

c. Failure of symptoms to improve within a reasonable time frame;

d. Review of specific management guidelines and possible complications related to treatment of disease process less familiar to the Physician Assistant;

e. At the request of the patient, Physician Assistant or Physician.

C. Standardized Procedures: Definition and Authority

1. The standardized procedures are designed to describe the steps of care for specific patient situations. They are used only in the following circumstances:

a. Assessment and management of patients;

b. Only Pharmacists and Physician Assistants may dispense, furnish and order drugs, appropriate to their scope of practice, with the following limitations:

(i) The Physician Assistant shall independently dispense, furnish and order drugs only within his/her professional expertise;

(ii) The Physician Assistant shall dispense, furnish and order drugs outside his/her professional expertise only in consultation with a supervising physician with the appropriate expertise;

(iii) All hospital formularies, policies and procedures shall be adhered to in the dispensing, furnishing and ordering of all drugs;

(iv) Drugs and devices to be dispensed, furnished and ordered independently are listed in the attached formulary protocol.

c. Manipulating human tissue, as appropriate to scope of practice.

2. Areas of practice that are recognized to be a part of Medicine, but may be performed by the Physician Assistant authorized by this protocol will be identified within a box.

3. In some practice areas, national medical guidelines or standards of care may also be referenced to supplement the standardized procedures and guide the patient care



process, but not to define it absolutely. Reference any other national guidelines or standards here and specify attachments, if applicable.

4. Other supporting references may be found in, but are not limited to:

Pharmacy Practice Act, 4052 Business and Professions Code

Physician Assistant Regulations, Title 16, Division 13.8

Business and Professions Code, RN Practice Act (1997), Division 2

Chapter 6, Article 2, sections 2725-2725.1, Article 8, sections 2834-2837

California Code of Regulations, Title 16, Division 14

Article 7, sections 1470-1474, Article 8, sections 1480-1485

California Code of Regulations, Title 22, Division 5

Chapter 5, Article 7, sections 70706-70706.2

UCSF Administrative Manual

UCSF Bylaws, Rules and Regulations

UCSF Formulary System

D. Qualifications for Physician Assistants

1. Education/Experience: Physician Assistant

Physician Assistants must have graduated from a Physician Assistant program ac-credited by the Council on Medical Education of the American Medical Association. All Physician Assistants must possess current licensure by the State of California as a Physician Assistant. Specify any other additional requirements, if applicable.

2. Credentials

Credentialing materials must be reviewed and approved by the Credentials Commit-tee, Executive Medical Board and Governance Advisory Council before the Physi-cian Assistant can provide care under a protocol. Credentials will be reviewed every 2 years.

E. Supervision

1. Approval of standardized procedures is a mandatory mode of physician supervision. Physician supervision is also provided in several other ways:

a. Direct on-site and phone supervision by an attending physician;

b. Review and co-signature of written medical records where specified;

c. Chart audits on random charts as an integral part of departmental and practice performance improvement programs;

d. Specify other modes of supervision, if applicable, such as patient care rounds and case presentations.

e. Direct observation of procedures with provider or designee in attendance.



F. Assessing Competency

1. Initial evaluation: Each Physician Assistant is directly observed providing patient care by the supervising physician or physician designee until the level of performance is determined to be satisfactory. Specify the exact nature of initial assessment of competency. At least three (3) direct observations are required. Signed competency certificates will be retained by the practitioner’s department.

2. Subsequent evaluations: Each Physician Assistant employed by UCSF receives an annual written performance evaluation by his/her Medical Director or designee. Physician Assistants who are not employees will be reviewed for recredentialing every two years.

3. Additional performance and quality improvement mechanisms may be identified and implemented at the discretion of the Medical Director or designee. Copies will be retained in Medical Center Administration or Ambulatory Services Administration, as appropriate.

G. Responsibility and Supervision

The supervising physician provides oversight for the Standardized Procedure and the Physician Assistant authorized to provide care as specified in this manner:

Supervising Physician

Name

Collaborates in development and implementation of Protocol and Procedures.

Provides initial competency assessment for Physician Assistant(s) working under Protocol and Procedures.

Provides ongoing supervision of Protocol and Procedures and annual competency assessments.

Physician Assistant

Legal name of Physician Assistant, degree(s) and

credentials

Collaborates in development and implementation of Protocol and Procedures.

Provides care per Protocol and Procedures.

Contacts supervising physician(s) as specified in Protocol and Procedures.

Furnishes medications and devices, orders tests and therapies as specified in Protocol and Procedures.



H. Record-Keeping Requirements

The Physician Assistant documents patient care in the medical record. Documentation may include history, physical, orders, laboratory results, procedure notes when applicable, diagnosis and appropriate treatment plans, instructions and signature, date and time.

Results of chart audits are reported as part of the department or practice’s quality improvement program.



I. Ordering Laboratory and Radiographic Diagnostic Studies

The Physician Assistant is authorized to order laboratory or other diagnostic studies as specified below following these guidelines:

1. Lab work such as CBC, chemistry panel, urinalysis, drug levels, serologies, liver function tests, cultures, type and screen or cross match, stool studies, etc., may be ordered as appropriate and specified in the protocol, using the Physician Assistant's name and the physician’s name on the requisition. Contact information such as the Physician Assistant’s pager number shall be provided with the requisition so that the physician can contact him/her if necessary. (If not applicable, delete this entire section or parts of this section)

2. Radiologic and/or other advanced studies (e.g., CT, MRI, etc.) will be ordered as specified in the protocol and as appropriate for the care of the patient after consultation with the physician. The Physician Assistant's name and the physician’s name are to be used on the requisition. Contact information such as the Physician Assistant’s pager number shall be provided with the requisition so that the physician can contact him/her if necessary. (If not applicable, delete this entire section or parts of this section)

J. Ordering Therapies

The Physician Assistant is authorized to order therapies such as respiratory or rehabilitative therapy or psychological counseling, consistent with their scope of practice and as appropriate for the care of the patient. The Physician Assistant's name and the physician’s name are to be used on the requisition.(If not applicable, delete this entire section)

K. Performing Advanced Procedures

The Physician Assistant is authorized to perform advanced procedures according to approved standardized procedures. Procedural consents will be obtained by the provider performing the procedure and must include who will be performing the procedure; type of anesthesia or pain medication; and benefits, risks, and alternatives associated with the procedure. These procedures include: Specify name(s) of procedure(s). (If not applicable, delete this entire section)

L. Ordering Medications

The Physician Assistant is authorized to order, adjust, and furnish medications as appropriate for the care of the patient and according to the formulary attached to this protocol. (If not applicable, delete this entire section)

M. Assisting in Surgery The Physician Assistant is authorized to function in the Operating Room as a First

Assistant or a Second Assistant in accordance with the AHP’s experience, training and certification. (If not applicable, delete this entire section)



II. Protocol for the Management of Acute and Chronic Illnesses and Injuries: Specify the Practice

A. Clinical Definition

This protocol covers the management of minor acute and stable illnesses and injuries, including but not limited to provide examples from scope of practice.

B. Data Base

1. Subjective Data:

a. Historical information relative to the presenting illness (past health history, family history, occupational history, personal/social history, review of systems);

b. Status of relevant symptom(s), e.g., present or stable.

2. Objective Data

a. Physical examination appropriate to the disease process;

b. Review of appropriate laboratory/diagnostic studies.

C. Assessment

Consistent with subjective and objective findings.

D. Management1. Diagnostic

a. Order relevant laboratory/diagnostic studies.

2. Treatment:

a. Physical and/or occupational therapy and/or speech therapy, if appropriate;

b. Diet and exercise prescription as indicated by the disease process and the patient condition;

c. Management of medication as appropriate to clinical expertise. (See attached formulary.)

3. Consultation

a. With emergent conditions requiring prompt medical attention;

b. With acute decompensation of the patient situation;

c. When there is a problem that is not resolving as anticipated with unexplained, historical, physical and/or laboratory findings;

d. Upon request of the patient, Physician Assistant, or physician;

e. When ordering expensive and/or unusual diagnostic studies;



f. When prescribing medications not within the clinical expertise of the Physician Assistant.

4. Patient/Family Education

a. In verbal and/or written format, the Physician Assistant explains to the pertinent party or parties involved the disease process, pertinent signs and symptoms, therapeutic modalities and appropriate follow-up.

5. Follow-up and referral

a. Performed in accordance with the standard of practice and/or with the consulting physician’s recommendation.

6. Record keeping

a. Patient contacts and visits are to be documented in accordance with standard practice and institutional policy.



UCSF MEDICAL CENTER and CHILDREN’S HOSPITALPHYSICIAN ASSISTANT

CERTIFICATION OF COMPETENCE: PROTOCOLS

Legal name of Physician Assistant, degree(s) and credentials, has successfully demonstrated competence in patient management utilizing the following protocol for the assessment and management of acute and chronic patients: Name of Protocol. Competency was assessed by Name of Supervising Physician. Continued proficiency will be documented below upon annual evaluation or re-credentialing and as circumstances require. After two years, this protocol must be reviewed by the Committee on Interdisciplinary Practices.

Initial Protocol Competency

Signature – Supervising Physician Date

This completed Competency Assessment sign-off must be returned to:Medical Staff Office

1600 Divisadero Street, Box 1639, Room C136San Francisco, CA 94115




PART II STANDARDIZED PROCEDURES PROCEDURE NAME

(To be used if a standardized procedure is not already available to add here)

Check all that apply (double-click on box and select the “Checked” button):

Adults Pediatrics Both Adults & Pediatrics

Inpatient Clinical Setting Outpatient Clinical Setting Both Inpatient & Outpatient Clinical Setting

I. Definition

Briefly describe the procedure. Include the intended outcome, or why the procedure is necessary.

II. Background Information

A. Setting (include physical addresses/locations of practice)Insert details

B. SupervisionInsert details

C. IndicationsInsert details - This would include the development of any change in the patient status, including, but not limited to: development of hypertension, cardiac arrhythmias, fluid retention, gastrointestinal difficulties, etc.

D. Precautions/ContraindicationsInsert details

III. Materials

Insert details - Include where to obtain if applicable.



IV. Name of Procedure Box text like this when any procedure overlaps with physician

A. Pre-treatment evaluationInsert details

B. Set up (if applicable)Insert details

C. Patient PreparationInsert details

D. ProcedureInsert details

E. Post-procedureInsert details

F. Follow-up treatmentInsert details

G. Termination of treatmentInsert details

V. Documentation

A. Written record

B. All abnormal findings are reviewed with supervising physician.

VI. Competency Assessment

A. Initial Competence1. Describe training

2. Describe treatments/procedures

B. Continued proficiencyInsert details




CERTIFICATION OF COMPETENCE: STANDARDIZED PROCEDURES

Legal name of Physician Assistant, degree(s) and credentials, has successfully demonstrated competence in patient management utilizing the following standardized procedure(s) for the assessment and management of acute and chronic patients: Name of Protocol. Competency was assessed by Name of Supervising Physician. Continued proficiency will be documented below upon annual evaluation or re-credentialing and as circumstances require. After two years, these procedures must be reviewed and renewed by the Committee on Interdisciplinary Practices.

1. Name of First Procedure (if applicable)

Initial Procedure Competency


2. Name of Second Procedure (if applicable)



3. Name of Third Procedure (if applicable)



4. Name of Fourth Procedure (if applicable)



This completed Competency Assessment sign-off must be returned to: UCSF Medical Staff Office

1600 Divisadero Street, Box 1639, Room C136San Francisco, CA 94115



APPENDIX A:DISPENSING, FURNISHING AND ORDERING OF DRUGS & DEVICES

Formulary List

If you have a DEA certificate, you must call Asst. Professor of Clinical Pharmacy, Alicia Sakai, to complete this medication formulary:

(415) 514.3941 or pager (415) 443.3235

Legal name of Physician Assistant, degree(s) and credentials here

(Double click on a gray box below to check-off)

Worked with Alicia Sakai to complete this formulary

NO DEA Certificate Active DEA Certificate. Class:

INSTRUCTIONS: Insert asterisk where category is not specific to practice and requires advance physician consultation and approval. Insert "NA" where category is not applicable to practice. Under "exceptions," specify agents that AHP(s) will not dispense, furnish or order without advance physician consultation and approval.

*/NA Medication Classes Typical Examples Exceptions

Analgesic Misc.

Antianxiety (non BZD)

Antibiotic

Anticoagulants-not heparin

Antidepressant

Antifungal

Antiplatelet

Antipsychotic

Antiseizure

Antiviral




Benzodiazepine (BZD)

Blood Modifier

Cardiovascular

Chemotherapy

Corticosteroid

Gastrointestinal

Heparin

Hormone

Insulin

IV Nutritional Therapy

Narcotic Analgesic

Narcotic PCA

NSAID

Nutritional Supplement

Oral Hypoglycemics/antidiabetic

TPN / Lipid

Transplant Immunosuppressant




Other (please specify)



APPENDIX B:DISPENSING, FURNISHING AND ORDERING OF DRUGS & DEVICES

Medication-Related References

Drug Information References UCSF Formulary (http://yew.ucsfmedicalcenter.org)Other updated references (please specify):

UCSF Policies and Procedures Medication-related Policies and Procedures:1. Administrative Manual (e.g. Sample Medication, Multi-dose

Vials, Patients’ Own Medications, Investigational Drugs, Medication Error Reporting Program)

2. Department of Pharmacy Policies and Procedures3. Department of Nursing Policies and Procedures4. By-laws (order-writing guidelines)

Clinical Guidelines/References for Care

UCSF Formulary (http://yew.ucsfmedicalcenter.org): click on Guideline/P&TOther Related/Relevant Guidelines (specify source or name, e.g. American Heart Association Guidelines or AMI)

Other


http://yew.ucsf.medicalcenter.org/

http://yew.ucsf.medicalcenter.org/

background and definitions

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