ARNP Protocol Letter
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.
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.