Collaboration Between Physicians and Advanced Practice Registered Nurses

Physicians are often contractually required to work with advanced practice registered nurses (APRNs) as part of their employment responsibilities.

Some physicians are asked to be the collaborating physician for an APRN. This article points out some of the legal requirements of the physician-APRN relationship. 

Advanced Practice Registered Nurses (“APRNs”) are nursing professionals with advanced degrees and specialized training. In order to address health professional shortages, many states, including Illinois, have granted APRNs independent practice authority to allow them to practice independently provided that they meet certain training and experience criteria. Other states require APRNs to enter into collaborative practice agreements with a physician. 

A collaborative practice agreement must be in writing and describe the relationship of the APRN with the collaborating physician.

Whether a collaborative practice agreement is required, can vary depending on the practice setting. States also frequently require a description of the categories of care, treatment, or procedures provided by the APRN. 

Requirements for collaboration vary from state to state, with some states setting specific limits on the number of APRNs a physician may collaborate with. For example, Illinois does not limit the number of APRNs a physician may collaborate with but warns that it could be a violation of the Illinois Medical Practice Act to enter into an “excessive number of written collaborative agreements with licensed advanced practice registered nurses resulting in an inability to adequately collaborate.” California limits the number of APRNs a physician may supervise to no more than four per provider. In Texas, a physician may not supervise more than seven full-time APRNs at a time, unless their practice is located in a health professional shortage area.

Be aware of different state laws when establishing a collaborative relationship.

Physician and APRN collaboration may be limited by state medical practice as well as nursing practice laws. Pay particular attention when practicing medicine across state lines, such as via telehealth. Other matters to consider:

• Whether a specific form of collaborative agreement is required by the state. For example, in Illinois, the agreement must conform to the requirements of Section 65-35 of the Nurse Practice Act. 
• Whether an employment relationship is required. For example, in Illinois, no employer/employee relationship is required between the collaborating physician and the APRN. 
• Whether the written collaborative agreement is for the same area of practice or specialty as the collaborating physician’s medical practice. 
• The methods of communication available to the APRN for consultation, collaboration, or patient referral. 
• Whether the collaborating physician is required to be personally present for certain aspects of patient care. 
• Whether the plan of care must be discussed and agreed upon in advance of rendering care? Is there a minimum number of medical records that must be reviewed on a regular basis and how are such reviews documented? 
• If prescriptive authority is granted, what types of medications can be prescribed? Is there a limit on the amount of medication that can be dispensed and whether refills are permitted? 

For further assistance contact: Aileen Brooks abrooks@mbhealthlaw.com