The health care industry and workers have always been an integral part of functional society. In today’s world, that is truer than ever. Nurse practitioners do important work with greater oversight than other licensed professionals in their field. Nurse practitioners (NPs) are regulated by two licensing Boards and must be licensed. The regulation is done by a special committee created just for nurse practitioners. Today we discuss what’s required for nurse practitioners to legally practice. We also give tips on how nurse practitioners can avoid professional license discipline.
Nurse Practitioners must have an active, permanent, unencumbered registered nursing license in North Carolina. Nurse practitioners do not have to have a medical license. However, a nursing license is not all that is required of nurse practitioners. The NC Board of Nursing (NCBON) and the NC Medical Board (NCMB) jointly regulate nurse practitioners. The NCBON and NCMB both comprise the NP Joint Subcommittee. Together they regulate NP licenses. NCGS §90-8.2 and NCGS §90-171.23(b)(14) are the general statutes that give the Joint Subcommittee the authority to implement rules to govern the practice of NPs in North Carolina.
Nurse practitioners must have approval to practice from both the NC Board of Nursing and the NC Medical Board. 21 NCAC 36 .0803 sets forth the Board of Nursing requirements for a NP to be able to register and practice as a nurse practitioner while 21 NCAC 32M .0101 through 21 NCAC 32M .0118 set forth the Medical Board requirements for NPs to practice as a nurse practitioner. A NP must also enter into a collaborative practice agreement with a licensed primary supervising physician. Below we get into detail the details of a collaborative practice agreement.
A collaborative practice agreement is a written agreement between a licensed NP and licensed physician that outlines their plan for operating their medical practice. The requirements for a valid collaborative practice agreement are found under 21 NCAC 32M .0110. The agreement must be reviewed at least yearly and acknowledged by a dated signature sheet signed by the physician and NP. Further, the agreement will need to include what tests, procedures, medical treatments may be ordered and performed by the NP. Also, the NP will need to stipulate what devices and drugs he/she is authorized to prescribe. Keep in mind that drug and device prescriptions need to be consistent with the requirements of 21 NCAC 32M .0109.
Meetings between the NP and primary supervising physician are also required monthly for the first six months of the agreement. After that, the scheduled meetings can be at least six months apart. All meetings must be documented, signed and dated by all attendees, and kept for 5 calendar years. Meeting documents must be available to Board members for review upon request. The meetings must discuss practice relevant clinical issues and quality improvement measures. There are additional requirements if a nurse practitioner is prescribing and/or dispensing medication.
First thing nurse practitioners should know is what is in their collaborative agreement with the primary supervising physician regarding prescriptions. For a NP to be able to prescribe a drug or device, the drug and/or device must be included in the collaborative practice agreement. If a NP is going to prescribe a controlled substance (as defined by the State and Federal Controlled Substances Acts) then there are additional requirements. The NP must have an assigned DEA number that is entered on each prescription for a controlled substance and refills. The prescriptions must be issued consistent with controlled substance laws and regulations. Also, the supervising physician must possess the same schedule(s) of controlled substances as the NP’s DEA registration. There is an exception to the requirement that NPs can only prescribe certain drugs and devices that are in the collaborative practice agreement.
“The nurse practitioner may prescribe a drug or device not included in the collaborative practice agreement only as follows: (A) upon a specific written or verbal order obtained from a primary or back-up supervising physician before the prescription or order is issued by the nurse practitioner; and (B) the written or verbal order as described in Part (b)(3)(A) of this Rule shall be entered into the patient record with a notation that it is issued on the specific order of a primary or back-up supervising physician and signed by the nurse practitioner and the physician.”
If a nurse practitioner wants to dispense drugs and devices, the NP must obtain approval from the Board of Pharmacy. It is not enough if your supervising physician is registered to dispense drugs. NPs can only dispense drugs and devices while under the supervision of a licensed consulting pharmacist. The licensed pharmacist must have his/her own facility with a valid pharmacy permit.
A closed claims study completed in 2018 by ‘The Doctors Company’, a medical malpractice insurance provider, resulted in the following strategies being suggested for nurse practitioners. Have the collaboration agreements outline circumstances that require the NP to refer patients to the physician or seek a second opinion. The agreement should include a description of the level of supervision exercised by the physician. It should also include the number and frequency of chart reviews and co-signatures.
The study in 2018 found that the delay or failure in diagnosis was the most common patient allegation in claims filed against NPs and physicians. Patient assessment was the most common factor contributing to patient injury. The best way to avoid delay or failure in diagnosis is to complete a thorough clinical history and physical examination for each patient. The ability to engage patients and obtain accurate histories is essential when developing a differential diagnosis.
Physicians, NPs, and office staff should take the time to explore patient complaints, especially when similar complaints are made on return visits. This should help narrow down the underlying issue the patient is having. Policies and procedures for the office staff (including you and physicians) can help mitigate any complaints regarding obtaining accurate patient histories. Use patient intakes that have specific questions regarding patient history, family history, pain, symptoms, etc.
If you obtain accurate patient history, speak with the patient and have them answer questions in order to establish a diagnosis. NPs should ask the supervising physician to evaluate the patient if there is still uncertainty about a diagnosis. This is true for finding the appropriate testing needed to establish a diagnosis as well. Remember to thoroughly evaluate all age groups of patients presenting with chest pain. Some younger patients may have undiagnosed heart problems. Ask about family history in addition to the patient’s history as well as the patient’s ongoing pain and symptoms. When in doubt, consult your primary supervising physician. Biggest thing to do is work together with your supervising physician.
Protect yourself and your staff by having written policies and procedures in place. Require all staff to document the details of phone calls with patients, including any recommended follow-ups. Email the details of the telephone calls to the patients so they are aware of future appointment times, referrals, and/or prescriptions they need to pick up. One of the most frustrating things is having a client or patient not listen. Make sure you can document that you told them to do something involving their treatment. If you gave them a referral, make sure you follow up with them to check and make sure they made that appointment. Remember, always be HIPPA compliant and make sure you are sending any patient information only to the patient.
Now, this list is not exhaustive as to the common errors some NPs make that can affect her/his license. This list is covers some of the most common errors based on the aforementioned 2018 study. If you have a question or need representation for a professional license issue, contact our office at 919-521-8810.
*This blog post does not establish an attorney-client relationship nor should be construed to be legal advice.