Finding a Collaborating Physician in North Carolina
For nurse practitioners (NPs) aspiring to establish their practice in North Carolina, finding the right collaborating physician is an essential step to success.
North Carolina is a Reduced Practice Authority state and a collaborating physician is required for NPs.
Navigating the process of identifying a suitable collaborating physician can be both challenging and rewarding. We’ve created a guide for identifying and establishing a compliant collaboration with a physician in the Tar Heel State.
Read on to learn more!
What Is the State Practice Environment for NPs in North Carolina
In which category does the state fall: NP independent practice, transition to independence, or collaboration required?
A collaboration is required. North Carolina is classified as a Restricted Practice Authority state.
Delegation Authority and Process
Is an agreement required?
Yes, an agreement is required.
What form of agreement is required and what are the requirements for the substance of the agreement (is use of state template required?)
The agreement must include:
The drugs, devices, medical treatments, tests, and procedures that may be prescribed, ordered, and performed by the nurse practitioner consistent with 21 N.C.A.C. 36.0809.
A predetermined plan for emergency services.
Where must the agreement be stored?
An agreement must be maintained at each practice site.
Does the agreement need to be filed with the state?
The Board of Nursing and Board of Medicine must approve the arrangement, but there is not an explicit requirement to file the collaboration agreement.
Are there requirements to file the agreement after the initial filing (e.g., for updates or on a specified frequency)?
No explicit requirement to file the collaboration agreement.
Who must sign the agreement?
The collaboration agreement must be signed and dated by both the primary supervising physician and the APRN.
How often must the agreement be reviewed/reauthorized?
The agreement must be reviewed at least yearly. This review must be acknowledged by a dated signature sheet, signed by both the primary supervising physician and the nurse practitioner, appended to the collaborative practice agreement.
What are the qualifications for the collaborating provider (licensure, same scope, active practice in state, etc.)?
The designated primary supervising physician must hold a valid license to practice medicine in North Carolina.
What are the qualifications for the NP?
Prior to the performance of any medical acts, a nurse practitioner must:
Meet registration requirements as specified in 21 NCAC 36 .0803 and 21 NCAC 32M.0103
Submit an application for approval to practice
Submit any additional information necessary to evaluate the application as requested
Have a collaborative practice agreement with a primary supervising physician
The nurse practitioner cannot practice until notification of approval to practice is received from the Board of Nursing after both Boards have approved the application.
Is an alternate collaborating physician required?
An alternate physician is not required. Back-up supervision shall be in compliance with the following:
The signed and dated agreements for each back-up supervising physician(s) shall be maintained at each practice site.
A physician in a graduate medical education program, whether fully licensed or holding only a resident's training license, shall not be named as a back-up supervising physician.
A fully licensed physician in a graduate medical education program who is also practicing in a non-training situation and has a signed collaborative practice agreement with the nurse practitioner and the primary supervising physician may be a back-up supervising physician for a nurse practitioner in the non-training situation.
See more information at the North Carolina Board of Nursing website here.
Collaboration Requirements
Are there ratios/limits on the number of NPs that a collaborator may supervise or enter into collaboration agreements with?
There are no requirement regarding ratios/limits on the number of NPs that a collaborator may supervise.
Is there an express requirement to review a certain number/percentage of charts?
No, but see Quality Improvement Process below.
Is there a requirement to meet and, if so, how often and how?
During the first six months of a collaborative practice agreement between an APRN and the primary supervising physician, there shall be monthly meetings to discuss practice-relevant clinical issues and quality improvement measures. Documentation of the meetings shall:
Identify clinical issues discussed and actions taken
Be signed and dated by those who attended
Be available for review by either Board for the previous five calendar years and be retained by both the APRN and primary supervising physician.
Quality Improvement Process:
The primary supervising physician and the APRN shall develop a process for the ongoing review of the care provided in each practice site, including a written plan for evaluating the quality of care provided for one or more frequently encountered clinical problems.
This plan shall include a description of the clinical problem(s), an evaluation of the current treatment interventions, and if needed, a plan for improving outcomes within an identified time frame.
The quality improvement process shall include scheduled meetings between the primary supervising physician and the APRN for a minimum of every six months. Documentation for each meeting shall:
Identify clinical problems discussed, including progress toward improving outcomes as stated in item (b), and recommendations, if any, for changes in treatment plan(s);
be signed and dated by those who attended; and
be available for review by either Board for the previous five calendar years and be retained by both the APRN and primary supervising physician.
Are there proximity requirements (e.g., between the NP/collaborator or practice site)?
There are no proximity requirements.
Are there location-specific requirements (e.g., that collaborator must go to practice site at some frequency)?
No onsite physical presence is not required; however, the supervising physician must be continuously available to the APRN for consultation by direct communication or telecommunication.
Is remote supervision allowed, or are there limitations on remote supervision?
Yes, the primary or back-up supervising physician(s) and the APRN shall be continuously available to each other for consultation by direct communication or telecommunication.
Physician and NP Filing Requirements
Outside of filing the collab agreement, must the physician and/or NP file any separate forms (e.g., notice of delegation of prescriptive authority, notice of collaboration, notice to PDMP, etc.)?
Applications for approval of changes in practice arrangements for an APRN currently approved to practice in North Carolina shall be submitted by the applicant as follows:
Addition or change of primary supervising physician shall be submitted to the Board of Nursing and processed pursuant to protocols developed by both Boards; and
Request for change(s) in the scope of practice shall be submitted to the Joint Subcommittee.
Prescribing Requirements and Controlled Substance Prescribing
What are the prescription requirements?
Each prescription shall be noted on the patient's chart and include the following information:
Medication and dosage;
Amount prescribed;
Directions for use;
Number of refills; and
Signature of APRN.
Prescription Format:
All prescriptions issued by the APRN shall contain the name of the patient and the APRN’s name and telephone number;
The APRN assigned DEA number shall be written on the prescription form when a controlled substance is prescribed
The APRN may obtain approval to dispense the drugs and devices other than samples included in the collaborative practice agreement for each practice site from the Board of Pharmacy, and dispense in accordance with 21 NCAC 46 .1703.
What are the requirements for controlled substance prescribing?
Schedules II-V controlled substances may be prescribed if outlined in the Collaborative Practice Agreement and if the APRN meets certain additional requirements:
The APRN has an assigned DEA number that is entered on each prescription for a controlled substance;
Refills may be issued consistent with Controlled Substance laws and regulations; and
The primary supervising physician(s) shall possess a schedule(s) of controlled substances equal to or greater than the APRN’s DEA registration.
The APRN may prescribe a drug or device not included in the collaborative practice agreement only as follows:
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 APRN; and
The written or verbal order as described in (A) 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 APRN and the physician.
Sources
North Carolina Board of Nursing: APRN Registration
North Carolina Board of Nursing: NP Position Statement
North Carolina Board of Nursing: Collaborative Practice Guidelines
