COLLABORATIVE PRACTICE RULE
The State Board of
Nursing’s and State Board of Registration for the Healing Arts’ joint
rulemaking activity on collaborative practices by physicians with registered
professional nurses (RNs) or registered professional nurses who are advanced
practice nurses (APNs) became law on September 30, 1996. This rule, 4 CSR 200-4.200 Collaborative
Practice (Nursing) or 4 CSR 150-5.100 Collaborative Practice (Healing Arts),
specifies the practice boundaries of physicians and RNs or physicians and APNs
engaged in written collaborative practice arrangements. You can access the Collaborative Practice
Rule at http://www.sos.mo.gov/adrules/csr/current/4csr/4c200-4.pdf.
Collaborative practice
arrangements (CPAs) are defined in state statute (334.104 RSMo) as written
agreements, jointly agreed-upon written protocols, or written standing orders for the delivery of health care
services. Through a CPA a physician may
delegate:
·
To an RN who is not an APN the authority to
administer or dispense drugs and provide treatment within the RN’s scope or
practice and consistent with the RN’s skill, training and competence; and
·
To an RN who is an APN the authority to
administer, dispense, and prescribe drugs and provide treatment.
An RN does not need to
engage in a CPA with a physician nor
require physician oversight to perform “nursing acts” the RN has the
specialized education, judgment, and skill to perform [335.016 (9) (a) through
(e) RSMo]. If the RN, however, is to
perform delegated “medical acts“ (e.g., dispensing of drugs*), a physician-RN
or physician-APN relationship must clearly and defensibly be in place.
A professional
relationship between a physician and RN or APN can be established and exercised
through the traditional means of specific, and later cosigned, verbal orders
from a physician or written orders, possibly in the form of protocols or
standing orders, generated and signed by a physician and carried out by an RN
or APN. In this case, the relationship
is not based on a jointly agreed-upon practice arrangement and therefore, would
not constitute a collaborative practice arrangement and the collaborative
practice rule would not apply.
On the other hand, a
physician-RN or physician-APN relationship can also be established and
exercised through one or more of the jointly agreed-upon physician and RN or
physician and APN written means described above. In this case, a written collaborative practice arrangement exists
and the collaborative practice rule applies.
Collaborating
physicians and collaborating RNs or APNs practicing in association with public
health clinics providing specific population-based health services must abide
by the statute provisions in 334.104 RSMo and sections (1) and (5) only
of the collaborative practice rule (4 CSR 200-4.200). The specific services are
as follows: immunizations; well child
care; HIV and sexually transmitted disease care; family planning; tuberculosis
control; cancer and other chronic diseases and wellness screenings; services
related to epidemiological investigations and related treatment; and prenatal
care.
If
services provided in public health clinics include diagnosis and initiation of
treatment of any other disease or injury than those listed above, then all
other rule provisions [sections (2), (3), and (4)] apply. Although
collaborating professionals whose practice activities meet the above
population-based health services are not bound to address all the rule
provisions in their written collaborative practice arrangements, they may find
inclusion of other rule provisions to be in the best interest of reasonable,
prudent, and defensible practice.
Additionally, some
rule provisions are required practices pursuant to other state or federal laws
whether or not one is in a written collaborative practice arrangement. An example of this are several provisions
regarding drug administration and dispensing behaviors in section (3) (I) of
the Collaborative Practice Rule (4 CSR 200-4.200).
*NOTE: Dispensing of drugs is not authorized
in the Nursing Practice Act. It is a delegated “medical act” which requires
written authorization to perform. (See rule, 4 CSR 150-5.020 Nonpharmacy
Dispensing which follows this section.)
Either the traditional means described above, or a written collaborative
practice arrangement may be used to document physician authorization to
dispense.
REFERENCE:
Missouri State Board
of Nursing (1998), Registered Professional Nurse/Advanced Practice Nurse
Information Packet
4
CSR 200-4.200-Collaborative Practice Rule
Chapter
334.104-Collaborative Practice Arrangements
Chapter
335 RSMo-State of Missouri Nursing Practice Act