STANDARD CARE ARRANGEMENT

CERTIFIED NURSE PRACTITIONER

This Standard Care Arrangement/Collaborative Practice Agreement (SCA) is a

written formal guide for planning and evaluating the health care of clients cared for
by the advance practice nurse practitioner (APRN). This SCA has been developed in
accordance with Section 4723.431 and the Ohio Revised Code (ORC) and Rules
adopted by the Board of Nursing (OBN) for the with Prescriptive Authority.

An SCA shall be entered into before engaging in practice as an APRN. The APRN may
enter into an SCA with one or more collaborating physicians. The APRN must
submit to the board the name and business address of each collaborating physician.
The APRN will notify the Board of Nursing of the collaborating physician and any
additions or deletions of a collaborating physician or any changes in the name and
or business address of a collaborating physician no later than (30) days after such
changes take effect. In the event of a termination of the SCA, the APRN will notify
the OBN and begin a 120-day buffer period, allowing the APRN to continue practice
while obtaining another collaborating physician. A new SCA shall be executed
when the APRN engages in practice with a different collaborating physician or
podiatrist.

Each collaborating physician must be authorized to practice in the state of Ohio,

practice in a specialty that is the same or similar to the APRNs specialty. Also, this
SCA shall terminate upon the termination of the APRNs employment with the
Practice. The most current copy of the SCA shall be retained and available upon
request at all sites where the APRN practices.

I. Scope of Practice

The APRN is a registered nurse with advanced educational preparation and

specialty training at the graduate or doctoral degree level. The APRN holds national
certification in an area of specialty as approved by The Ohio Board of Nursing.

II. Statement of Services

Daniela Tangeman (APRN) may provide and manage care to individual patients
and groups with complex health problems and provide health care services that
promote, improve, and manage health within the APRNs specialty and educational
preparation and clinical preparation in the area of critical care.

The APRN, in collaboration with the undersigned physician(s) practicing at ___Upper

Valley Medical Center________, may provide preventive and primary care services,
evaluate, and promote patient wellness. Unless formally amended, by adding the
signatures of additional physicians to this SCA, _____Dr. Czajka____________, M.D. will
be the primary collaborating physician and _____Dr. Kaibas__________; M.D. will be the
alternate collaborating physician.
III. Incorporation of New Technology or New Procedures
The APRN will identify new technology/new procedures needed in his/her clinical
practice. The APRN will, as is deemed appropriate in his or her professional
judgment and in that of his/her collaborating physician, incorporate those new
technologies/procedures and consistent with the lawful scope of his/her practice.
Educational in-services and conferences will be utilized as part of this process.

IV. CRITERIA FOR REFERRAL AND CONSULTATION OF A PATIENT

The APRN shall determine when referral to or consultation with the collaborating
physician is necessary. The APRN will consult with Dr. __Czajka_________ (or other
physicians of the practice) or refer patients to such physician (s) in situations
including, but not limited to the following:
a. Request from a patient to see the collaborating physician.
b. A patient whose clinical condition is unusual, who is not making satisfactory
progress, or whose condition is unresponsive to the plan of care.
c. Patient with complicated diagnoses and multifaceted treatment outside
parameters established by the APRN and the collaborating physician.
d. Any other reason as determined by the APRN and the collaborating physician.

Consultation options include, but are not limited to, telephone contact, on-site case
review or discussion, and physical examination of the patient by the collaborating
physician. The consultation shall be documented in the patient’s record.

V. COVERAGE OF ABSENCE

In the event of an emergency or planned absence of a collaborating physician, the

APRN will be notified with the name of an alternate collaborating physician.

VI. POLICY FOR RESOLUTION OF CLINICAL DISAGREEMENTS

In the event of a disagreement between the APRN and the collaborating physician
regarding a matter of patient management that is within the scope of practice for
both parties, the APRN and physician shall work together to resolve the
disagreement professionally and expeditiously. One or more of the following
resolutions should be followed:

a. Refer to current professional literature (journals, research, and texts)

appropriate to the area in question.
b. Consult with a specialist in the area in question.

Appropriate institutional chain-of-command Chief/Medical Director, Service Line

Director, and Chief of Nursing Officer shall assist with arbitration.

VII. PRESCRIPTIVE AUTHORITY

The prescriptive authority of the APRN shall not exceed the prescriptive authority of
the collaborating physician(s) hereunder. Additionally, the APRN’s prescriptive
authority shall be subject to the following:

a. The APRN may prescribe any drugs or therapeutic devices for indications
approved by the Food and Drug Administration; except the APRN may not prescribe
any drugs or therapeutic devices that are on the exclusionary formulary adopted
from time to tome by the OBN committee on prescriptive governance (the
“Exclusionary Formulary”).

b. The APRN may prescribe Schedule II controlled substances subject to Ohio

revised code 4723-9-10. The following limits apply to opioid analgesics prescribed
for the treatment of acute pain:
 Extended-release or long-acting opioids shall not be prescribed.
 Non-opioid treatment options must be considered first.
 Opioids may only be prescribed after a history and physical determines a
need for prescription.
 The patient has been advised of the benefits and risks of the opioid
(including a potential for addiction), and this is documented on the record.
 The presumption is a three-day supply or less is frequently sufficient.
 Not more than a seven-day supply of opioids may be prescribed for adults,
with no refills.
 Not more than a five-day supply of opioids may be prescribed for minors,
with no refills, and only after the written consent of the parent or guardian is
obtained.
 The seven and five-day limits may be exceeded for pain expected for pain
expected to persist for a longer period as long as a 30 MED average per day is
maintained and the APRN documents in the patient record the reason for
exceeding the time and why a non-opioid medication is not appropriate.

VIII. OHIO AUTOMATED Rx REPORTING SYSTEM (OARRS) REPORTING

Per Ohio law 4723-9-12 the APRN must register for an OARRS account.
Circumstances that deem an OARRS history report be requested:
 Before initially prescribing or personally furnishing an opioid analgesic
or benzodiazepine to a patient, the prescriber must request information
from OARRS that covers at least the previous 12 months.
 The prescriber must also make periodic requests for patient information
from OARRS if the course of treatment continues for more than 90 days.
 The APRN must document in the patient’s medical record that the report
was received and the information assessed.

IX. QUALITY ASSURANCE PROVISIONS

The APRN shall participate in quality assurance processes as requested by the
collaborating physicians and documented by the Ohio Administrative Code (OAC)
4723-8-05

The APRN and collaborating physician(s) shall jointly review effectively the SCA at
least once every two years.

Each practicing APRN who is party to the SCA shall participate in a quality assurance
process and shall provide documentation satisfactory to the OBN. The quality
assurance process shall include at a minimum:

1. Periodic random chart review at least annually by a collaborating physician,

or a designated member of a quality committee. The collaborating physician
shall, on a continuous basis, review a sampling of the APRNs prescribing
pattern – such reviews shall occur no less than semi-annually per Ohio law.
2. After each chart review, a conference between the collaborating physician, or
a designated member of a quality committee; and
3. The quality assurance process shall include a process for patient evaluation
of the APRN’s care.

Every two years, the APRN shall verify the licensure status of each collaborating
physician with whom the APRN has an effective SCA. Verification of licensure status
may be obtained from the Ohio e-license center. The APRN shall document that
such verification was obtained.

The APRN must comply with all continuing education requirements to maintain
licensure under ORC 4723.24, 4723.41, and 4723.42

X. ARRANGEMENT REGARDING REIMBURSEMENT

Reimbursement procedures must comply with the medical assistance program as

outlined in division (C) of section 5111.02 renamed 5164.02 of the ORC.
APRN

Name ___Daniela Tangeman___ Specialty________ Cardiology__________ Practice Area

Upper Valley Medical Center__________
Business address 3006 N Co Rd 25 A #104 Troy, OH
45373___________________________________________________________________
Phone: _____937 335-3518________________________________ Beeper
___________________________________
Signature ______Daniela Tangeman_____________________ Date April 9, 2018

Physician

Name ____William Czajka_ ___ Specialty_______ Cardiology___________ Practice Area

Upper Valley Medical Center 3006 N. Co Rd 25 A #104 Troy, OH_________________
Phone: _____________________________________ Beeper ___________________________________
Signature ___________________________________ Date _____________________________________

Physician

Name _________________________Specialty__________________ Practice Area _____________

Business address ______________________________________________________________________
Phone: _____________________________________ Beeper ___________________________________
Signature ___________________________________ Date _____________________________________