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CENTENNIAL MEDICAL CENTER
ALLIED HEALTH PROFESSIONAL
NURSE PRACTITIONER (ADVANCED PRACTICE NURSE) IN EMERGENCY MEDICINE
PRACTICE PREROGATIVES
APPLICANT’S NAME: _______________________________________DATE:___________________
 INITIAL
 CHANGE IN PRACTICE PREROGATIVES
 RENEWAL OF PRACTICE PREROGATIVES
To be eligible to request these clinical practice prerogatives, the applicant must meet the following threshold
criteria:
Definition:
Basic Education:
Minimal Formal Training:
Licensure:
Certification:
Malpractice Insurance:
General Scope of
Services/Functions:
Categories of Patients
Practitioner may Treat:
Competency
Requirements:
Life Safety Certifications:
Prescriptive Authority:
An Advance Practice Nurse is defined by the Texas Board of Nursing (TBON Rules and Regulations Section
219.2 Definition) as “A registered nurse authorized by the Board to practice as an advanced practice nurse
based on completing an advanced practice nursing educational program acceptable to the Board. The term
includes a nurse practitioner, nurse-midwife, nurse anesthetist, and a clinical nurse specialist. The advanced
practice nurse is prepared to practice in an expanded role to provide health care to individuals, families, and/or
groups in a variety of settings including, but not limited to homes, hospitals, institutions, offices, industry,
schools, community agencies, public and private clinics, and private practice. The advanced practice nurse acts
independently and/or in collaboration with other health care professionals in the delivery of health care services.”
Graduate from a post basic advanced practice nurse program at the certificate or master’s degree level (eg MSN
or MS).
In addition to being an RN, the applicant must demonstrate successful completion of an Nurse Practitioner
master’s degree nursing accredited program from an accredited institution in the applicant’s specialty area or
must demonstrate successful completion a formal postgraduate Nurse Practitioner track or program (within the
applicant’s specialty area) within an accredited school of nursing program granting graduate-level academic
credit (e.g., graduate, nonmatriculating program). The Nurse Practitioner has attended a post basic advanced
practice nurse program at the certificate or master’s degree level. (TBON Rules and Regulations, Section 219.1
Accredited Program - A program that has been determined to have met the standards set by a national
advanced practice nursing education accrediting body recognized by the Board).
Current unrestricted licensure as an Advance Practice Nurse by the Texas State Board of Nurse Examiners and
approved for advanced practice.
Successfully completion of certified nurse practitioner program in requested specialty area and board
certification by the National Commission on American Academy of Nurse Practitioners (AANP) or American
Nurses Credentialing Center (ANCC).
Proof of malpractice insurance in the amounts of $200,000/$600,000 as a minimum with applicant’s name listed
as the insured.
May provide only those services for which he/she is specifically authorized according to this scope of practice.
Only patients of the documented and approved Supervising Physician(s).
Initial Applicant: Each initial applicant shall submit documentation (either from their training program or from an
accredited institution) of at least 24 cases demonstrating the provision of inpatient services in the last 24
months. If applicant is unable to provide documentation of 24 cases in the last 24 months, the Chief of Medicine
will assign an additional level of focused review appropriate for the practice prerogatives requested to ensure
current clinical competence. Applicants have the burden of producing information deemed adequate by the
hospital for a proper evaluation of current competence, and other qualifications and for resolving any doubts.
Reappointment: Each practitioner must be able to provide documentation of at least 24 cases, from an
accredited institution, demonstrating the provision of inpatient services in the last 24 months. If the practitioner
has not performed the sufficient number of cases at this hospital, he/she will be requested to provide appropriate
documentation from another accredited institution to demonstrate his/her current clinical competence. If an
applicant is unable to provide documentation of 24 cases in the last 24 months, the Chief of Medicine will assign
an additional level of focused review appropriate for the practice prerogatives requested to ensure current
clinical competence.
None
An approved BNE number for prescriptive authority must be issued for prescriptive authorization. Pre-signed
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CENTENNIAL MEDICAL CENTER
ALLIED HEALTH PROFESSIONAL
NURSE PRACTITIONER (ADVANCED PRACTICE NURSE) IN EMERGENCY MEDICINE
PRACTICE PREROGATIVES
APPLICANT’S NAME: _______________________________________DATE:___________________
Clinical References:
Medical Record
Responsibility:
Supervising Physician
Requirement:
Professional Practice
Evaluation:
Reappointment
Requirement:
prescriptions by the supervising physician may be carried out according to the protocols that authorize diagnosis
of the patient’s condition and treatment.
Initial Applicant: Training Director from the applicant’s training program (if completed program within past 5
years) or Chief of Medicine from the primary hospital where applicant has been affiliated within the past year and
two additional peer references who have recently worked with the applicant and directly observed his/her
professional performance over a reasonable period of time and who will provide reliable information regarding
current clinical competence, ethical character and ability to work with others.
Reappointment: A letter of reference from the Chairman of the applicant’s primary practicing facility or a peer
reference, preferably from CMC current medical staff, who has recently worked with the applicant and directly
observed his/her professional performance over a reasonable period of time and who will provide reliable
information regarding current clinical competence, ethical character, health status and ability to work with others.
Clearly, legibly, completely and in a timely fashion describe each service he or she provides to a patient in the
hospital and relevant observation. Standard rules regarding authentication of, necessary content of, and
required time frames for preparing and completing the medical record and portions thereof are applicable to all
entries made with facility documentation requirements. All documentation in the medical record must be cosigned by the supervising physician.
Degree of Supervision: A physician on the medical staff shall recommend an individual applying for practice
prerogatives. The applicant shall participate in the management and care of patients under the general
supervision or direction of the Supervising Physician. Supervising Physician is a member in good standing of the
Centennial Medical Center medical staff and currently licensed and in good standing by the Texas Medical
Board. Must have continuous supervision (by telecommunications or in person) by the supervising / sponsoring
physician.
Initial Applicant: A period of focused professional practice evaluation (may include chart review, monitoring
clinical practice patterns, proctoring, external peer review, and discussions with other individuals involved in the
care of patient) will be followed as outlined in the Focus Professional Practice Evaluation (FPPE) policy.
Reappointment: A period of ongoing professional practice evaluation (may include chart review, monitoring
clinical practice patterns, proctoring, external peer review, and discussions with other individuals involved in the
care of patient) will be followed as outlined in the Ongoing Professional Practice Evaluation (OPPE) review
policy.
Reappointment shall be based on unbiased, objective results of care according to documentation of clinical
activity within the scope of practice prerogatives requested. Applicants must be able to demonstrate that they
have maintained competence by showing evidence that they have provided an adequate volume of tests or
procedures commensurate with the subspecialty for which practice prerogatives are requested over the
reappointment cycle. In addition, continuing medical education related to these practice prerogatives may be
required.
If you meet the threshold criteria above, you may apply for those practice prerogatives appropriate to your training and
current competence. Any practitioners who hold the following practice prerogatives prior to the revision date are
grandfathered for those practice prerogatives; however, all practitioners must meet any new criteria defined for maintaining
practice prerogatives at reappointment.
Applicant: Place a check in the (R) column for each practice prerogative requested. All applicants must provide
documentation of the number of hospital cases treated during the past 24 months.
(R)
(A)
GENERAL PRACTICE PREROGATIVES
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Supporting
documentatio
n of number
of patients or
procedures
performed in
FPPE
See below
plus
additional
cases at
discretion
Reappt Criteria
If no cases or
insufficient cases,
additional
proctoring may be
required, may
CENTENNIAL MEDICAL CENTER
ALLIED HEALTH PROFESSIONAL
NURSE PRACTITIONER (ADVANCED PRACTICE NURSE) IN EMERGENCY MEDICINE
PRACTICE PREROGATIVES
APPLICANT’S NAME: _______________________________________DATE:___________________
the past 24
months,
preferably at
CMC

#R
1#

#
G
1
#
Nurse Practitioner Core Practice prerogatives
Patient management
➤ Perform history and physical exam
➤ Administer medications and perform other emergency treatment
➤ Assess for levels of comfort (e.g., pain, palliative care, end of life, bad
news) and initiate appropriate interventions
➤ Complete EMTALA-specified medical screening examination (MSE)
➤ Counsel and instruct patients, families, and caregivers as appropriate
➤ Direct care as specified by medical staff–approved protocols
➤ Initiate appropriate referrals
➤ Order and initial interpretation of diagnostic testing and therapeutic
modalities, such as laboratory tests, medications, hemodynamic
monitoring, treatments, x-ray, EKG, IV fluids and electrolytes, etc.
➤ Perform sexual assault examination
➤ Record progress notes
➤ Specifically assess and initiate appropriate interventions for violence,
neglect, and abuse (e.g., physical, psychological, sexual, substance)
➤ Specifically assess and initiate appropriate interventions and
disposition for suicide risk
➤ Triage patients’ health needs/problems
➤ Dictate discharge summaries
Anesthesia
➤ Inject local anesthetics
➤ Perform regional nerve block and digital nerve block
Diagnostic procedures
➤ Anoscopy
➤ Arthrocentesis (e.g., knee, elbow)
➤ Compartment pressure measurement
➤ Insert and remove nasogastric tube
➤ Perform slit-lamp examination
➤ Tonometry
Genital/urinary
➤ Perform urinary bladder catheterization (e.g., Foley, suprapubic)
Head and neck
➤ Control of epistaxis
➤ Removal of rust ring
Resuscitation
➤ Cardiopulmonary resuscitation
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________
of proctor
include privilege
specific CME
Review of 3
representat
ive cases.
Current
demonstrated
competence and
provision of care for
approximately 24
inpatients and/or
outpatients in past 2
years.
CENTENNIAL MEDICAL CENTER
ALLIED HEALTH PROFESSIONAL
NURSE PRACTITIONER (ADVANCED PRACTICE NURSE) IN EMERGENCY MEDICINE
PRACTICE PREROGATIVES
APPLICANT’S NAME: _______________________________________DATE:___________________
➤ Neonatal resuscitation
Hemodynamic techniques
➤ Insert and remove arterial catheters
➤ Insert and remove central venous catheters
➤ Intraosseous infusion
➤ Peripheral venous cutdown
Skin and wound care management
➤ Apply, remove, and change dressings and bandages
➤ Debridement, suture, and general care for superficial wounds and
minor superficial surgical procedures
➤ Laceration repair—simple, intermediate, complex
Obstetrics
➤ Assist with imminent childbirth and postdelivery maternal care

#R
2#

#R
3#

#R
4#

#
G
2
#
Other techniques
➤ Arterial puncture and blood gas sampling
➤ Perform excision of thrombosed hemorrhoids
➤ Remove foreign bodies (ears, nose, rectum, soft tissue, throat, vaginal)
➤ Replace gastrostomy tube
➤ Incision and drainage of abscess
➤ Insert Heimlich (small gauge) valve
➤ Perform ear, nose, rectum, soft tissue, throat, vaginal, and gastric
lavage
➤ Perform venous punctures for blood sampling, cultures, and IV
catheterization
➤ Trephination of nails and removal of nails
Skeletal procedures
➤ Fracture/dislocation immobilization techniques (e.g., casting, splinting)
➤ Fracture/dislocation reduction techniques
➤ Spine immobilization techniques
Prescriptive Authority
Write prescriptions per schedule, Schedule is : ____________(eg. III-V)
Criteria/No. of Procedures:
Must have current and unrestricted DEA and DPS

#
G
3
#
Prescriptive Authority
Verbal prescriptive orders, Schedule is : ____________(eg. III-V)

#
G
REMOVAL FROM GENERAL PRACTICE PREROGATIVES: Should
applicant’s current practice limitations or current competence exclude
performance of any practice prerogatives specified in the list of core
Criteria/No. of Procedures:
Must have current and unrestricted DEA and DPS
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CENTENNIAL MEDICAL CENTER
ALLIED HEALTH PROFESSIONAL
NURSE PRACTITIONER (ADVANCED PRACTICE NURSE) IN EMERGENCY MEDICINE
PRACTICE PREROGATIVES
APPLICANT’S NAME: _______________________________________DATE:___________________

#R
5#
4
#
practice prerogatives, please indicate here. Applicant and/or MEC must
document reasons for exclusion.
___________________________________________________________
___________________________________________________________
SPECIAL PROCEDURES/TECHNIQUES - If desired, noncore practice
prerogatives are requested individually, in addition to requesting the core.
To be eligible to apply for a special procedure listed below, the applicant
must demonstrate successful completion of an approved, recognized
course when such exists, or acceptable supervised training in residency,
fellowship or other acceptable experience, and provide documentation of
competence, case logs, in performing that procedure consistent with the
criteria set forth in medical staff policies governing the exercise of specific
practice prerogatives.

#
G
5
#
Exercise Testing
________
Criteria/No. of Procedures
As indicated in the American College of Physicians/ACC/AHA task force
statement on clinical competence in exercise testing, exercise testing in
select patients can be performed safely by an appropriately trained
nurse/mid level practitioner under the supervision of a physician, who
should be in the immediate vicinity (on campus) and available for
emergencies. Must be ACLS trained and certified and demonstrate
supervision of at least 100 stress tests, with substantiating documentation
with review and recommendation from Chairman of Cardiology and
Centennial Administration.
ADDITIONAL PRACTICE PREROGATIVES: A request for any additional
practice prerogatives not included on this form must be submitted to the
Medical Staff Office and will be forwarded to the appropriate review
committee to determine the need for development of specific criteria,
personnel and equipment requirements.
EMERGENCY: In the case of an emergency, any individual who has been
granted clinical practice prerogatives is permitted to do everything
possible within the scope of license, to save a patient’s life or to save a
patient from serious harm, regardless of staff status or practice
prerogatives granted.
First 3
cases to be
reviewed,
and
proctored,
if
applicable.
Demonstrated
current
demonstrated
competence and
evidence of the
performance of at
least 10 cases in
past 24 months.
Recommending Individual/Committee must note: (A) = Recommend Approval as Requested. NOTE: If conditions or modifications are noted, the specific
condition and reason for same must be stated below.
ACKNOWLEDGEMENT OF APPLICANT
I certify that I meet the minimum threshold criteria to request the above practice prerogatives and have provided documentation to support my
eligibility to request each group of procedures requested. I have requested only those practice prerogatives for which by education, training, current
experience and demonstrated performance I am qualified to perform and for which I wish to exercise at Centennial Medical Center, and I understand
that:
(a) in exercising any clinical practice prerogatives granted, I am constrained by hospital and medical staff bylaws, rules & regulations, policies and
rules applicable generally and any applicable to the particular situation
(b) any restriction on the clinical practice prerogatives granted to me is waived in an emergency situation and in such situation my actions are
governed by the applicable section of the medical staff bylaws or related documents
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CENTENNIAL MEDICAL CENTER
ALLIED HEALTH PROFESSIONAL
NURSE PRACTITIONER (ADVANCED PRACTICE NURSE) IN EMERGENCY MEDICINE
PRACTICE PREROGATIVES
APPLICANT’S NAME: _______________________________________DATE:___________________
Signed:___________________________________________________
Date: ___________________
ACKNOWLEDGEMENT OF SUPERVISING PHYSICIAN
As Supervising Physician, I shall be a member in good standing of the Centennial Medical Center medical staff, maintain a current licensed and in
good standing by the Texas Medical Board. The Supervising Physician must:
- Assume responsibility for supervision or monitoring the Allied Health Professional’s practice as stated in the appropriate hospital or medical staff
policy governing Allied Health Professionals,
- Be available or provide an alternate to provide consultation when requested and to intervene when necessary and
- Assume responsibility for the care of any patient when requested by the Allied Health Professional or required by this policy or in the interest of
patient care.
_____________________________
Supervising Physician’s Name – Print
_____________________________
Signature
_____/_____/_____
Date
_____________________________
_____________________________ _____/_____/_____
Supervising Physician’s Name – Print
Signature
Date
Department Chair’s Recommendation
I certify that I have reviewed and evaluated this individual’s request for practice prerogatives, the verified credentials, quality data and/or other
supporting information. Based on the information available and/or personal knowledge, I recommend the following:
Department Chair Signature: ______________________________________________ Date: _______________________
 Recommend practice prerogatives as requested
 Do not recommend the requested practice prerogatives due to: _________________________________
 Recommend requested practice prerogatives with the following conditions/modifications: ___________________________________________
Credentials Committee Review/Recommendation Action Date: _______________________________________
 Recommend practice prerogatives as requested
 Do not recommend the requested practice prerogatives due to: _________________________________
 Recommend requested practice prerogatives with the following conditions/modifications: ____________________________________________
Medical Executive Committee Review/Recommendation Date: ________________________________________
 Recommend practice prerogatives as requested
 Do not recommend the requested practice prerogatives due to: ________________________________
 Recommend requested practice prerogatives with the following conditions/modifications: _____________________________________________
Governing Board Decision Date: __________________________________________________________
 Recommend practice prerogatives as requested
 Do not recommend the requested practice prerogatives due to: ________________________________
 Recommend requested practice prerogatives with the following conditions/modifications: _____________________________________________
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CENTENNIAL MEDICAL CENTER
ALLIED HEALTH PROFESSIONAL
NURSE PRACTITIONER (ADVANCED PRACTICE NURSE) IN EMERGENCY MEDICINE
PRACTICE PREROGATIVES
APPLICANT’S NAME: _______________________________________DATE:___________________
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