Center for Advanced Practice Nursing and Allied Health


Protocols are mandated by the Tennessee Board of Medical Examiners (Chapter 0880-6-.02, Tennessee Board of Medical Examiners Rules and Regulations) and are defined as written guidelines for medical management.  (http://state.tn.us/sos/rules/0880/0880-06.pdf)

  • Shall be jointly developed and approved by the supervising physician and nurse practitioner;
  • Shall outline and cover the applicable standard of care;
  • Shall be reviewed and updated biennially;
  • Shall be maintained at the practice site;
  • Shall account for all protocol drugs by appropriate formulary;
  • Shall be specific to the population seen;
  • Shall be dated and signed; and
  • Copies of protocols and formularies shall be maintained at the practice site and shall be made available upon request for inspection by the respective boards.

Additionally, VUMC requires all protocols be formatted in the new protocol format. Please follow the steps listed below:

  • Transfer content into the new format
  • Revise content, if needed
  • Enter the current date in the protocol header
  • Verify the supervising physician listed is correct
  • Check that all references are up to date
  • Be sure to include any attachments referred to that are not readily accessible via the web.

For practices utilizing authoritative textbooks, web based guidelines or other published materials please use the reference text template.

Submit revised/updated protocol(s), using the attached template, with a cover sheet to capnah@vanderbilt.edu. Once submitted protocols will follow the endorsement/approval process illustrated below

Protocols are maintained on the CAPNAH Sharepoint Site at: 

Please note you must have a vanderbilt vunet id and be granted access to view the CAPNAH Protocols Warehouse. Please contact Kim Drake at kimberly.m.drake@vanderbilt.edu or by calling 615/322-8917 to request access.

This page was last updated April 27, 2015 and is maintained by