Most patients have certain expectations when they go to the doctor. They generally expect to see an actual physician. However, the reduction in medical payments from Medi-Care and private insurance has necessitated changes in the usual physician/patient relationship. One change that has created big changes in the relationship has been the use of nurse practitioners.
The nurse practitioner (NP) is a registered nurse who possesses additional education and training in physical diagnosis, psycho-social assessment, and management of health-illness needs in primary health care. The NP has been prepared in a program that conforms to Board standards as specified in California Code of Regulations and Standards of Education.
Primary Health Care
Primary health care is when a consumer makes contact with a health care provider who assumes responsibility and accountability for the continuity of healthcare regardless of the presence or absence of disease. (California Code of Regs., § 1480 (b).) In primary health care, the NP may be the only health professional to see the patient. The NP will employ a combination of nursing and medical functions approved by standardized procedures. The NP must be clinically competent and he or she will possess and exercise the degree of learning, skill, and care ordinarily possessed and exercised by a member of the appropriate discipline in clinical practice. (California Code of Regs., § 1480(c)).
Legal Authority for Practice
The NP acts utilizing standardized procedures to perform medical functions (California Code of Regs.,
§ 1485). § 2725 of the Nursing Practice Act (NPA) provides authority for nursing functions that are also essential to providing primary health care which do not require standardized procedures. Examples include physical and mental assessment, disease prevention and restorative measures, performance of skin tests and immunization techniques, and withdrawal of blood, as well as authority to initiate emergency procedures. In order to exceed the scope of a RN, they must utilize standardized procedures. Without standardized procedures the NP is legally very vulnerable, regardless of having been certified as a RN, who has acquired additional skills as a certified nurse practitioner.
Registered nurses who have been certified as NPs by the California Board of Registered Nursing may use the title nurse practitioner and place the letters “R.N., N.P.” after their name. Additionally a NP could be registered with other expertise, including adult nurse practitioner, pediatric nurse practitioner, obstetrical-gynecological nurse practitioner, and family nurse practitioner. (California Code of Regs.,
§ 1481). Since 2008, any new applicant will be required for initial qualification to possess a master’s degree in nursing, a master’s degree in a clinical field related to nursing, or a graduate degree in nursing, and to have satisfactorily completed a nurse practitioner program approved by the board. (Business and Professions Code § 2835.5.)
Furnishing Drugs and Devices
The law also authorizes NPs to obtain and utilize a “furnishing number” to furnish drugs and devices. Furnishing or ordering drugs and devices by the nurse practitioner is defined to mean the act of making a pharmaceutical agent or agents available to the patient in strict accordance with a standardized procedure. Furnishing is carried out according to a standardized procedure. All nurse practitioners who are authorized pursuant to § 2831.1 to furnish or issue drug orders for controlled substances shall register with the United States Drug Enforcement Agency.
Controlled Substances must be furnished under physician and surgeon supervision. Standards are contained at Business & Professions Code § 2836.1. A prescription pad may be used as transmittal order forms as long as they contain the furnisher’s name and furnishing number. Pharmacy law requires the nurse practitioner’s name on the drug and/or device container label. The name of the supervising physician is no longer required on the drug/device container label. (Business & Professions Code
§ 1470 (f).)
Business and Professions Code § 2725.1 allows registered nurses to dispense (hand to a patient) medication upon the valid order of a physician in primary, community, and free clinic. Business and Professions Code § 2725.1 was amended to extend to furnishing nurse practitioner authority to dispense drugs, including controlled substances, pursuant to standardized procedures or protocols in primary, community, and free clinics.
Other Areas Where Nursing Practitioners Work
Through collaboration among administrators and health professionals, including physicians, surgeons and nurses, pursuant to § 2725, standardized procedures may be implemented that authorize a nurse practitioner to do any of the following:
(1) Order durable medical equipment, subject to any limitations set forth in the standardized procedures.
(2) After performance of a physical examination by the nurse practitioner and collaboration with a physician and surgeon, certify disability pursuant to § 2708 of the Unemployment Insurance Code.
(3) For individuals receiving home health services or personal care services, after consultation with the treating physician and surgeon, approve, sign, modify, or add to a plan of treatment or plan of care.
Sign for the Request and Receipt of Pharmaceutical Samples and Devices
Certified furnishing nurse practitioners are authorized to sign for the request and receipt of complimentary samples of dangerous drugs and devices identified in their standardized procedures or protocols that have been approved by the physician. (Business & Professions Code § 4061 [Pharmacy law].)
§ 120582 of the Health and Safety Code provides:
(a) Not withstanding any other provision of law, a physician and surgeon who diagnoses a sexually transmitted chlamydia, gonorrhea, or other sexually transmitted infection, as determined by the Department of Health Services, in an individual patient may prescribe, dispense, furnish, or otherwise provide a prescription antibiotic drugs to the patient’s sexual partner or partners without examination of that patient’s partners.
(b) A nurse practitioner practicing as a certified nurse-midwife may dispense, furnish, or otherwise provide a prescription antibiotic drug to the sexual partner or partners of a patient with a diagnosed sexually transmitted infection, as determined by the Department of Health Services, without examination of the patient’s sexual partners.
Workers’ Compensation Reports
Labor Code § 3209.10 gives nurse practitioners the ability to cosign a Doctor’s First Report of Occupational Injury or illness for a worker’s compensation claim to receive time off from work for a period not to exceed three (3) calendar days if that authority is included in standardized procedure or protocols. The treating physician is required to sign the report and to make a determination of any temporary disability.
Veterans with Disabilities Parking Placards
The Vehicle Code is amended to include nurse practitioners, nurse midwives and physician assistants as authorized health care professionals that can sign the certificate substantiating the applicant’s disability for the placard. Existing law authorizes the Department of Motor Vehicles to issue placards to persons with disabilities and veteran with disabilities and temporary distinguishing placards to temporary disabled persons, to be used for parking purposes. Prior to issuing the parking placard or temporary placard, the Department of Motor Vehicles requires the submission of a certificate, signed by an authorized health care professional providing a full description substantiating the applicant’s disability, unless the disability is readily observable and uncontested.
Medical Examination School Bus Drivers
Vehicle Code § 12517.2 allows NP to examine school bus drivers for an original or renewal certificate to drive a school bus, school pupil activity bus, youth bus, general public paratransit vehicle, or farm labor vehicle.
Informing Patient: Positive and Negative Aspects of Blood Transfusions
The Health and Safety Code authorizes the nurse practitioner and the nurse-midwife who is authorized to give blood to provide the patient with information by means of a standardized written summary as developed or revised by the State Department of Public Health about the positive and negative aspects of receiving antilogous blood and direct and nondirected homologous blood to volunteers. Previous law required that the need for a blood transfusion be determined in most cases by a physician.
Medi-Cal Billing: Nurse Practitioner Nationally Certified in a Specialty
Welfare and Institutions Code allows that services provided by a certified nurse practitioner shall be covered under Medi-Cal to the extent authorized by federal law, and subject to utilization controls. The department shall permit a nationally certified nurse practitioner to bill Medi-Cal independently for his or her services. If a nationally certified nurse practitioner chooses to bill Medi-Cal independently for his or her service, the department shall make payment directly to the nurse practitioner. For the purposes of this section, “certified” means nationally board certified in a recognized specialty.
Supervision of the NP performing an overlapping medical function is addressed in the standardized procedure and may vary from one procedure to another depending upon the judgment of those developing the standardized procedure. As an example, in one women’s clinic the supervision requirement for performing a cervical biopsy was that a physician must be physically present in the facility, immediately available in case of emergency. For all other standardized procedure functions, the supervision requirement was for a clinic physician to be available by phone. The furnishing or ordering of drugs and devices by nurse practitioners occurs under physician and surgeon supervision. Physician and surgeon supervision shall not be construed to require the physical presence of the physician, but does include (1) collaboration on the development of the standardized procedure, (2) approval of the standardized procedure, and (3) availability by telephonic contact at the time the patient is being examined by the nurse practitioner. For furnishing purposes, the physician may supervise a maximum of no more than four (4) NPs at one time. (Business & Professions Code § 2836.1.)
Supervision of Medical Assistants
Nurse Practitioners and Certified Nurse-Midwives may supervise Medical Assistants in “community clinics” or “free clinics” in accord with approved standardized procedures and in accord with those supportive services the Medical Assistant is authorized to perform (Business and Professions Code
§ 2069(a)(1); and Health and Safety Code § 1204(a) & (b).) Examples of violations resulting in citation and fine are using the title “nurse practitioner” without being certified as a NP and failing to have standardized procedures when performing overlapping medical functions. NPs are encouraged to comply with all sections of the NPA to avoid discipline.
Written by Matthew L. Kinley