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A State-by-StateScope of Practice Guidefor Nurse PractitionersMedSource Consultants Whitepaper Series300 Main St. 6th Floor Stamford, CT 06901 800.575.2880medsourceconsultants.com [email protected]

In 2017, over 20 states passed legislation that positively impacted access to and delivery ofhealthcare to patients nationwide.Signature authority: Six states enacted legislation pertaining to full or partial global and partial signature recognition andauthority, including APRN authorization for certain aspects of care. Global signature authority is generally defined asauthorization for recognized APRNs to sign, certify, or endorse all documents related to healthcare within their scope ofpractice (SOP) provided for their patients. Some states limit these documents (partial) to a statutorily authorized list, whileothers are broader in their approach.APRN authority to sign death certificates among other documents is particularly important and was accomplished inArkansas (Act 372; enacted March 2017), Minnesota (HF 2177; effective May 2017), Nevada (Chapter 318; effectiveJanuary 2018), Texas (SB 919; effective June 2017), and Wyoming (Chapter 160; effective March 2017). North Carolina(Act 2017-111; effective July 2017) enacted legislation adding NPs to the list of providers authorized to sign handicapparking certificates.Recommendation for medical marijuana use: The District of Columbia joins Connecticut, Hawaii, Maryland, Maine, andNew York as states/districts that authorize APRNs as providers who may recommend the use of medical marijuana to aqualifying patient with a qualifying medical condition as described. Act 21-565, Medical Marijuana Omnibus AmendmentAct of 2016, was issued December 16, 2016. This authority does not confer prescriptive authority as marijuana is listedas a Schedule I controlled substance by the Drug Enforcement Administration (DEA). Designated APRNs in these stateshave authority to recommend the use of this substance as described by each state's law.Introductionwww.medsourceconsultants.com

Source:State Nurse State Practice ActsAnd Administration Rules, 2017 American Association of Nurse Practitioners, 2017www.medsourceconsultants.com

AlabamaAlabama is a reduced practice state that is regulated by the state Board of Nursing andBoard of Medical Examiners.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: Must have collaborative agreement with PhysicianPrescriptive Authority: CRNPs and CNMs may prescribe, administer, and providetherapeutic tests and drugs within a BON- and BOME-approved formulary. CRNPs andCNMs in collaborative practice with a physician may prescribe controlled substances inSchedules III, IV, and V pursuant to the rules of the Alabama BOME Chapter 540-X-18.CRNPs and CNMs are required to complete 12 continuing medical education contacthours in advanced pharmacology and prescribing trends and 4 additional contact hoursevery 2 years for renewal of the Qualified Alabama Controlled Substances Certificateunder current regulation for Schedule III-V controlled substance authority.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.1www.medsourceconsultants.com

AlaskaAlaska is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree, national certification and a consultationand referral plan.Practice Authority: Full Independent Practice.Prescriptive Authority: Authorized APRNs have independent Rx authority—including SchedulesII-V controlled substances—and may apply for DEA registration. APRNs are legally required toreview the Prescription Drug Monitoring Program database prior to prescribing controlledsubstances. They are legally authorized to request, receive, and dispense pharmaceuticalsamples in Alaska. Prescriptions are labeled with the APRN's name only. To renew Rxauthority, APRNs must complete 12 contact hours of continuing education (CE) in advancedpharmacotherapeutics, including 2 CE hours in opioid prescribing each 2-year renewal cycle.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.2www.medsourceconsultants.com

ArizonaArizona is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: No formal physician collaboration agreement required. However, ArizonaDepartment of Health regulations require that patients admitted to an acute care facility musthave an attending physician.Prescriptive Authority: NPs have full Rx and dispensing authority, including controlledsubstances Schedules II-V, on application, and fulfillment of BON-established criteria. The Boardof Nursing allows an NP to prescribe and dispense drugs and devices within the NP’s populationfocus (e.g. family-individual across life span, adult-gerontology primary or acute care, neonatal).An NP may also prescribe Schedules II-V controlled substances. Ariz. Admin. Code §4-19-511,Ariz. Admin. Code §5-19-512.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.3www.medsourceconsultants.com

ArkansasArkansas is a reduced practice state that is regulated by the state Board of Nursing.Licensure requirements : RN license, graduate degree and national certification.Legal Authority: No collaborative practice agreement required for APRNs. RNPs must practice inaccordance with protocols developed in collaboration with a practicing physician.Prescriptive Authority: The NPA authorizes the BON to provide a certificate of Rx authority toqualified APRNs. A collaborative practice agreement with a practicing physician (who hastraining in scope, specialty, or expertise to that of the APRN and use of Rx protocols) is required.APRNs with Rx authority may apply for and hold a DEA number. The NPA limits the prescribing ofcontrolled substances to Schedules III-V and hydrocodone-combination products from Schedule IIof the Controlled Substance Act (with authorization from the physician on the collaborativepractice agreement). Neither protocols nor collaborative practice agreements with a physicianare required unless the APRN has Rx authority.This state allows nurse practitioners prescriptive authority for drugs falling into schedule III, IV orV.4www.medsourceconsultants.com

CaliforniaCalifornia is a restricted practice state that is regulated by the state Board of RegisteredNursing.Licensure Requirements : RN license and a graduate degree.Practice Authority: Nurse practitioners and physicians must enter a collaborative agreement forone or more elements of NP practice. Currently in 2018, California state has found themselvesentrenched in unsuccessful lobbying efforts to enhance the role of NPs.Prescriptive Authority: Drugs or devices prescribed by the NP must be ordered in accordancewith the policies and protocols set forth in the agreement with the supervising physician. TheNP may prescribe drugs and devices within the NP’s area of practice. Physician involvement isrequired when the NP is prescribing Schedule II or III controlled substances, and a patientspecific protocol is required. Cal. Bus. & Prof. Code §2836.1This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.5www.medsourceconsultants.com

ColoradoColorado is a full practice state that is regulated by the state Board of Nursing.Licensure requirements include: RN license, graduate degree and national certification.Practice Authority: A nurse practitioner can evaluate and diagnose patients, order and interpretdiagnostic tests and initiate and manage treatments, including the power to prescribemedication. APNs must complete a 1,000-hour documented prescribing mentorship period(provisional Rx authority) with a physician or an APRN and registration with the DEA.Prescriptive Authority: An NP is authorized by the State Board of Nursing to prescribe drugsafter certain requirements are met, including educational classes and a preceptorship. Uponconclusion of meeting the requirements, provisional authority may be granted and the NP mayprescribe drugs and Schedule II-V controlled substances. A mentorship with a physician or NPwith full prescriptive authority must be completed within three years after receiving provisionalauthority. An articulated plan for safe prescribing must also be developed in the mentorship.Colo. Rev. Stat. §12-38-111.6, Colo. Board of Nursing Rules Chapter 15.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.6www.medsourceconsultants.com

ConnecticutConnecticut is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: NPs practice under the licensure authority of the State Board of Nursing instead of alicensed physician. For the first three years after initial licensure, the NP must collaborate with aphysician.Prescriptive authority: Full prescriptive authority is given with licensure and after 3 years and no lessthan a 2,000-hours of collaborative practice under a physician. APRNs and CNMs are legally authorizedto request, receive, and dispense pharmaceutical samples. The collaboration must include a method toreview patient outcomes. After three years, the NP may prescribe independently. Conn. Gen. Stat.§20-87a(3).This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III, IV or V.7www.medsourceconsultants.com

DelawareDelaware is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: Full independent practice authority granted after two years of practiceunder a collaborative agreement with a physician.Prescriptive Authority: APRNs may apply for independent practice after successfully practicingunder a collaborative agreement within a hospital or integrated clinical setting (between aphysician, podiatrist, or licensed Delaware healthcare delivery system and an APRN) for atleast 2 years and a minimum of 4,000 full-time hours. APRNs licensed by the BON mayprescribe, order, procure, administer, store, dispense, and furnish OTC, legend, and controlledsubstances pursuant to applicable state and federal laws and within the APRN's role andpopulation focus.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.8www.medsourceconsultants.com

District ofColumbiaWashington, D.C. is a full practice district that is regulated by the state Board of Nursing.Licensure requirements include: RN license, graduate degree and national certification.Practice Authority: Full independent practice authority.Prescriptive Authority: In the District of Columbia, a nurse practitioner can evaluate anddiagnose patients, order and interpret diagnostic tests and initiate and manage treatments,including the power to prescribe medications. APRNs must hold DEA registration.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.9www.medsourceconsultants.com

FloridaFlorida is a restricted practice state that is regulated by the state Board of Nursing and Boardof Medicine.Licensure requirements: RN license, graduate degree and national certification.Practice Authority: A written protocol between an NP and the supervising physician is required.Prescriptive Authority: In Florida nurse practitioners must be supervised by a physician toprovide patient care and write prescriptions. Master's- or doctoral degree-prepared ARNPs areauthorized by supervisory protocol to prescribe, dispense, administer, or order any drug,including Schedules II-V controlled substances as authorized in a BON-adopted controlledsubstances formulary with certain exceptions. Additionally, psychiatric mental health boardcertified ARNPs may prescribe psychotropic controlled substances.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.10www.medsourceconsultants.com

GeorgiaGeorgia is a restricted practice state that is regulated by the state Board of Nursing and theComposite Medical Board.Licensure Requirements include: RN license, graduate degree and national certification.Practice Authority: A written protocol is required between the NP and the supervising physician.Prescriptive Authority: NPs and their physician supervisors must work together under a written"nurse protocol". The nurse protocol is a written document in which the physician gives the NPauthority to perform medical acts and also agrees to be available for immediate consultationwith the nurse practitioner.This state allows nurse practitioners prescriptive authority for drugs falling into schedule III, IVand V.11www.medsourceconsultants.com

HawaiiHawaii is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: NPs may practice independently from physicians and practice underlicensure authority of the State Board of Nursing.Prescriptive Authority: NPs are recognized in state policy as primary care providers. In Hawaii,the BON regulates APRN Rx authority, and APRNs have legal authority to prescribemedications, including Schedules II-V controlled substances independently pursuant to anexclusionary formulary established by the BON. APRNs with Rx authority are legally authorizedto request, receive, and dispense manufacturers' prepackaged pharmaceutical samples.APRNs may not request, receive, or sign for controlled substance samples; however, they mayprescribe, order, and dispense medical devices and equipment.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.12www.medsourceconsultants.com

IdahoIdaho is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: An NP is a licensed independent practitioner who shall practice consistentwith the definition of advanced practice registered nursing, recognized national standards, andthe standards set forth by the Board of Nursing rules.Prescriptive Authority: NPs are recognized in state policy as primary care providers. Apopulation focus is the section of the population which the NP has targeted to practice within.The categories of population focuses are family/individual across the life span, adultgerontology, women’s health/gender-related, neonatal, pediatrics and psychiatric-mentalhealth. Idaho Admin. Code §23.01.01.271.14.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.13www.medsourceconsultants.com

IllinoisIllinois is a reduced practice state that is regulated by the state Board of Examiners forNursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: In Illinois, a collaborative agreement is required for all clinical practice,except for practice within a hospital or ambulatory surgical treatment center.Prescriptive Authority: An NP’s prescriptive authority must be outlined in the collaborativeagreement. NPs may prescribe prescription drugs and Schedules III-V controlled substances.Schedule II controlled substances may be prescribed if delegated by the supervising physicianand if certain requirements outlined in the rules are met. 225 ILCS §65/65-40.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.14www.medsourceconsultants.com

IndianaIndiana is a reduced practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license and completion of graduate degree or RN license andcompletion of NP certificate program along with national certification.Practice Authority: In Indiana, nurse practitioners are required to establish a collaborativeagreement with a physician in order to practice and prescribe medication.Prescriptive Authority: An NP may prescribe prescription drugs and Schedules II-V controlledsubstances if outlined in the written collaboration agreement and after certain requirements aremet. 848 IAC §5-1-1.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.15www.medsourceconsultants.com

IowaIowa is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: NPs have full independent practice authority.Prescriptive Authority: Authorized ARNPs are granted full, independent Rx authority within theirspecific role and population focus, including Schedules II-V controlled substances. ARNPs mayprescribe, deliver, distribute, or dispense noncontrolled and controlled drugs, devices, andmedical gases, including pharmaceutical samples. ARNPs must register with the DEA, andprescriptions written by ARNPs must be labeled with their name.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.16www.medsourceconsultants.com

KansasKansas is a reduced practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: In Kansas, nurse practitioners are required to establish a collaborativeagreement/written protocol with a responsible physician.Prescriptive Authority: APRNs, with the exception of CRNAs, are legally authorized to prescribemedications, including Schedules II-V controlled substances pursuant to a collaborativepractice agreement and written protocol.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.17www.medsourceconsultants.com

KentuckyKentucky is a reduced practice state that is regulated by the state Board of Nursing.Licensure Requirements include: RN license, graduate degree and national certification.Practice Authority: The NP is required to have a collaborative agreement with a supervisingphysician for prescribing medications.Prescriptive Authority: An NP may prescribe legend drugs under a collaborative agreement witha physician. If an NP has met certain requirements after four years, the NP may prescribe drugsindependently. If the NP wishes to prescribe Schedule II-V controlled substances, thecollaborative agreement must remain in place. Ky. Rev. Stat. §314.042.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III, IVor V.18www.medsourceconsultants.com

LouisianaLouisiana is a reduced practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: A collaborative practice agreement is required and includes parametersagreed upon by the NP and the supervising physician.Prescriptive Authority: APRNs have Rx authority in Louisiana, including Schedules II-V controlledsubstances. The BON has sole authority to develop, adapt, and revise R&R governing SOP,including Rx authority, the receipt and distribution of sample and prepackaged drugs, andprescribing legend and controlled drugs. An APRN who is granted limited Rx authority mayrequest approval to prescribe and distribute controlled substances as authorized by the APRN'scollaborating physician if the patient population is served by the collaborative practice.This state allows nurse practitioners prescriptive authority for drugs falling into schedule III, IVand V.19www.medsourceconsultants.com

MaineMaine is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduation from NP Program and national certification.Practice Authority: APRNs licensed by the BON are defined as CNPs, CNMs, CNSs, and CRNAs.CNSs practice in an independent role; however, a CNP who qualifies as an APRN must practicefor at least 24 months under the supervision of a licensed physician, NP, or must be employedby a clinic or hospital that has a medical director who is a licensed physician.Prescriptive Authority: NPs may prescribe prescription drugs and Schedules II-V controlledsubstances once registered with the U.S. Drug Enforcement Administration. Me. Code of Regs.§02.380.008 Section 7.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III, IVor V.20www.medsourceconsultants.com

MarylandMaryland is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduation from NP program and national certification.Practice Authority: A nurse practitioner must consult and collaborate with a physician or nursepractitioner for the first 18 months of practice.Prescriptive Authority: NPs are recognized in state policy as a primary care provider. A primarycare provider is a nurse practitioner certified in any of the following areas of specialization:adult, pediatric, geriatric, OB/GYN, school nurse or family.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III, IVor V.21www.medsourceconsultants.com

MassachusettsMassachusetts is a restricted practice state that is regulated by the state Board of Registration inNursing and Board of Registration in Medicine.Licensure requirements include: RN license, graduate degree and national certification.Practice Authority: A written collaboration agreement required between the NP and thesupervising physician. This agreement must be mutually developed and agreed to by thephysician and the NP.Prescriptive Authority: A written collaboration agreement must include prescriptive guidelinesdeveloped by the physician. Eleven items must be outlined in the agreement including the scopeof the NP’s prescribing practice and the types of medication that may be prescribed. Mass. Reg.Code §243-2.10 (5)This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III, IVor V.22www.medsourceconsultants.com

MichiganMichigan is a restricted practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license and national certification. Practice Authority: Supervision by a licensed physician is required. Delegation of tasks andfunctions to the NP must fall within the NP’s scope of practice.Prescriptive Authority: APRNs are authorized to prescribe nonscheduled prescription drugs;prescribing of Schedules II-V controlled substances is authorized as a delegated act of aphysician and must include the APRN and physician names and DEA numbers.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III, IVor V.23www.medsourceconsultants.com

MinnesotaMinnesota is now a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license and national certification.Practice Authority: The Minnesota BON grants APRNs the authority to practice and regulatestheir practice. APRNs include CNP, CNS, CNM, and CRNA roles. APRNs have independentpractice in Minnesota.Prescriptive Authority: APRNs may prescribe, receive, dispense, and administer drugs, includingSchedules II-V controlled substances independently. CRNAs must hold a written prescribingagreement with a physician when providing nonsurgical pain therapies for chronic painsymptoms. APRNs must register with the DEA, and they have statutory authority to request,receive, and dispense sample medications.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III, IVor V.24www.medsourceconsultants.com

MississippiMississippi is a reduced practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: Nurse practitioners in Mississippi are required to establish a collaborativeagreement with a physician in order to treat patients and prescribe drugs.Prescriptive Authority: An NP may prescribe prescription drugs and Schedules II-V controlledsubstances after completing a Mississippi State Board of Nursing approved educationalprogram.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.25www.medsourceconsultants.com

MissouriMissouri is a restricted practice state that is regulated by the state Board of Nursing.Licensure requirements include: RN license, graduation from NP program and nationalcertification.Practice Authority: In Missouri, nurse practitioners are required to establish a collaborativeagreement with a physician in order to practice and prescribe medication.Prescriptive Authority: Prescriptive authority and privileges must be outlined in the writtenpractice agreement. Drugs dispensed must be within the NP’s scope of practice. If outlined in theagreement, the NP may prescribe Schedules II-V controlled substances. Mo. Code of State Reg.§20-2200-4.200(3).This state allows nurse practitioners prescriptive authority for drugs falling into schedule III, IVand V.26www.medsourceconsultants.com

MontanaMontana is a full practice state that is regulated by the state Board of Nursing.Licensure requirements include: RN license, graduation from NP Program and nationalcertification.Practice Authority: The Montana BON grants APRNs authority to practice and regulates theirpractice. APRNs include CNP, CNS, CNM, and CRNA roles.Prescriptive Authority: NPs are recognized in state policy as primary care providers. NPpractice means the independent and/or collaborative management of primary and/or acutehealth care of individuals, families and communities across settings. The NP is certified inacute or primary care and in the population focus of adult/geriatric, pediatric, neonatal,family/individual health across the life span, women’s/gender-related, and/or psychiatric/mental health.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.27www.medsourceconsultants.com

NebraskaNebraska is now a full practice state that is regulated by the state Board of Advanced PracticeRegistered Nurses.Licensure requirements include: RN license, graduation from NP program and nationalcertification.Practice Authority: A collaborative practice agreement is required only for the first 2,000 hoursof practice under the supervision of a physician or nurse practitioner.Prescriptive Authority: An NP may prescribe medications that fall within the NP’s scope ofpractice.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.28www.medsourceconsultants.com

NevadaNevada is a full practice state that is regulated by the state Board of Nursing.Licensure Requirements: RN license, graduate degree and national certification.Practice Authority: Before full independent practice authority, an NP must have a regulatedrelationship with a physician for prescribing Schedule II controlled substances for 2,000 hoursor two years.Prescriptive Authority: NPs are recognized in state policy as primary care providers. An NP whowishes to obtain a license to practice as an advanced practice registered nurse must requestthat the State Board of Nursing issue the license to specify the role of the applicant and thepopulation of focus of the applicant within that specific role. The State Board of Nursingrecognizes the following populations of focus: 1) women’s health or gender-specific health; 2)family health and caring for a patient across the life span of the patient; 3) mental health; 4)adult health; 5) gerontology; 6) pediatrics; 7) neonatal; and 8) any other population of focusapproved by the board. Nev. Admin. Code §632.2597(5).This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.29www.medsourceconsultants.com

New HampshireNew Hampshire is a full practice state that is regulated by the state Board of Nursing.Licensure requirements: RN license, graduate degree and national certification.Practice Authority: An NP has full independent practice authority and is licensed by the NewHampshire State Board of Nursing.Prescriptive Authority: NPs are recognized in state policy as primary care providers. Healthcare professionals qualified to be considered primary care providers include advancedregistered nurse practitioners licensed by the New Hampshire board of nursing in the advancepractice categories of family practice, internal medicine or pediatrics.This state allows nurse practitioners prescriptive authority for drugs falling into schedule II, III,IV or V.30www.medsourceconsultants.com

New JerseyNew Jersey is a reduced practice state that is regulated by the state Board of Nursing.Licensure requirements include: RN license, graduation from NP program and nationalcertification.Practice Authority: Nurse practitioners in New Jersey can independently diagnose and treatpatients without physician involvement. However, a nurse practitioner must have acollaborative agreement with a physician or a physician’s supervision or delegation in order toprescribe drugs.Prescriptive Authority: APNs credentialed by the BON have full Rx authority, includingSchedules II-V controlled substances in accordance with a joint protocol, which has beenestablished by the APN and the collaborating physician. The joint protocol is required forprescribing drugs and devices only and is not a collaborative agreement for general practice.This sta

authority, APRNs must complete 12 contact hours of continuing education (CE) in advanced pharmacotherapeutics, including 2 CE hours in opioid prescribing each 2-year renewal cycle. This state allows nurse practitioners prescriptive au