Articulated Plan Template Name _____________________ RN # ____________APR #____________RXN # __________________ Role (check one): CNM_____ CNS______ CRNA______ NP ________ NP and CNS Population Focus: The area(s) in which you hold certification as an advanced practice nurse, check all that apply: Adult/ Geriatric Adult/Geriatric Adult Geriatric Family Acute Care Primary Care Pediatric Acute Pediatric Acute Women’s Neonatal Psychiatric/Mental Care Care Health Health Adult Health Medical/Surgical Other (specify) CERTIFICATION (list all active APN certifications, certifying organization and expiration dates). Certification: _______________________________________ Issued by: _________________________________________ Expiration date: ________________________________ Certification: _____________________________________ Issued by: _______________________________________ Expiration date: ___________________________________ Certification: ______________________________________ Issued by: ________________________________________ Expiration date: ____________________________________ CLINICAL PRACTICE (list all current practice settings) Practice Name:_____________________________________ Practice Address: ___________________________________ Practice Phone Number:______________________________ Type of Practice: ____________________________________ Consultation and Referral Mechanisms: I will maintain ongoing collaboration with physicians and other appropriate health care providers and a mechanism for referral, when appropriate, to physicians and other appropriate health care providers for issues related to prescriptive authority and safe prescribing. A written statement how the RXN will maintain ongoing collaboration with other health care professionals regarding issues Consultation Resources (list specific resources or contacts available for consultation regarding issues related to prescriptive authority and safe prescribing) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Referral Resources (list specific resources or health care provider contacts to whom you can refer patients or clients who are not within your scope of prescribing practice or in emergency situations) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________

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Quality Assurance Plan for Safe Prescribing: I will evaluate the quality of my prescribing practices as an independent prescriber using the following mechanisms. (identify frequency of audits or quality assurance mechanisms within an identified period of time): ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Decision Support Tools: I utilize the following decision support tools in my prescribing practice (list with specificity). ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Ongoing Continuing Education in Pharmacology and Safe Prescribing: Date___________ Title______________________________________________________ Instructor/Presenter/Author___________________________________ Date___________ Title______________________________________________________ Instructor/Presenter/Author___________________________________ Date___________ Title______________________________________________________ Instructor/Presenter/Author___________________________________ Date___________ Title______________________________________________________ Instructor/Presenter/Author___________________________________ Date___________ Title______________________________________________________ Instructor/Presenter/Author___________________________________ Date___________ Title______________________________________________________ Instructor/Presenter/Author___________________________________ Attestation of Development of Articulated Plan by Mentor for First Time Prescribers: Date Plan Created: _________________________________ RXN Signature: _____________________ Date: _________ Mentor Signature: ___________________ Date: _________ Mentor Name: _______________________ Mentor License#______________________ OR

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Attestation of Development of Articulated Plan by Attestor for Experienced Prescribers by Endorsement: (The Plan must be signed by a Colorado licensed Advanced Practice Nurse with Full Prescriptive Authority or a physician licensed in Colorado) Date Plan Created: _________________________________ RXN Signature: _____________________ Date: _________ Attestor Signature: ___________________ Date: _________ Attestor Name: ______________________ Attestor License#_____________________

Annual Review (RXN must sign and date to document annual review, use additional pages if needed) RXN Signature ______________________Review Date______________ RXN Signature ______________________Review Date______________ RXN Signature ______________________Review Date______________ RXN Signature ______________________Review Date______________ RXN Signature ______________________Review Date______________ Articulated Plan Update: Update the Plan when there is a change in your clinical practice setting(s) or when there is a significant change to any of the four prescribing standards. Update those sections of the Plan that have changed, copying the section format used in the template. Sign and date the Update. Updates do not require signature by an attestor nor should the Update be reported to the Board.

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