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Changes in Missouri collaborative practice law.

That part of Senate Bill 724, as truly agreed, finally passed and signed by the Governor affecting advanced practice registered nurses, will become law on August 28, 2008. It is fairly well known that this bill authorizes an advanced practice registered nurse (APRN), but excluding CRNAs, who hold a "certificate of controlled substance prescriptive authority" (Certificate) from the Board of Nursing (BON) and who is delegated the authority in a Collaborative Practice Agreement (CPA) to prescribe any controlled substance in Schedules III, IV and V, except for himself/herself or his/her family. What many are unaware of are the changes that this Bill requires for all CPAs between physicians and APRNs.

Controlled Substance Authority

To prescribe controlled substances, a APRN must first obtain a Certificate from the BON. To obtain the Certificate, an APRN must: 1) submit proof of successful completion of an advanced pharmacology course that includes preceptorial experience in the prescription of drugs, medicines and therapeutic devices; 2) provide documentation of a minimum of 300 clock hours preceptorial experience in the prescription of drugs, medicines and therapeutic devices with a qualified preceptor; 3) provide evidence of a minimum of 1,000 hours of practice as an APRN (none of which hours can be obtained in the APRN's education program); and 4) have a CPA delegating controlled substance prescribing authority with a physician who has an unrestricted DEA number and whose practice is comparable in scope, specialty and expertise to that of the APRN.

At this time, we do not know what kind of proof of completion, what type courses and experience, what documentation of clock hours, and what evidence of practice and qualifications of a preceptor will be required by the BON. This will have to await further guidance from the BON through position statements or regulations.

The law also requires that, in addition to the BON, the Healing Arts Board, Pharmacy Board and the Department of Healthand Senior Services all have to approve any rules and regulations that may be adopted relating to the prescription of controlled substances by APRNs. At this time, we don't know if the Boards will be trying to adopt rules, but if they do, it could take some time to obtain all the approvals.

We know that APRNs with controlled substance prescriptive authority will only be able to prescribe a 120 hour supply of any Schedule III narcotic controlled substance and that the CPA must contain a list of the controlled substances the APRN is authorized to prescribe.


CPA Requirements

SB 724 also imposes requirements on all CPAs involving APRNs; not just those with controlled substance prescriptive authority. By August 28, 2008, all CPAs involving APRNs should be modifi ed to include the following:

1. Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the APRN;

2. A list of all other offices or locations besides those listed in where the collaborating physician authorizes the APRN to prescribe;

3. A required posting at every office where the APRN is authorized to prescribe and a prominently displayed disclosure statement informing patients that they may be seen by an APRN and have the right to see the collaborating physician;

4. All specialty or board certifications of the collaborating physician and all certifi cations of the APRN;

5. The manner of collaboration between the collaborating physician and the APRN, including how they will:

(a) Engage in collaborative practice consistent with each professional's skill, training, education, and competence;

(b) Maintain geographic proximity; and

(c) Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician;

6. A list of all other written practice agreements of the collaborating physician and the APRN;

7. Th e duration of the written practice agreement between the collaborating physician and the APRN; and

8. A description of the time and manner of the collaborating physician's review of the APRN's prescribing practices. The description must include provisions that the APRN shall submit documentation of the APRN's prescribing practices to the collaborating physician within fourteen days. Th e documentation must include, but not be limited to, a random sample review by the collaborating physician of at least twenty percent of the charts and medications prescribed by the APRN.

Previously, only if the APRN was involved in the diagnosis and initiation of treatment for acutely or chronically ill or injured patients, was the collaborating physician limited to collaborating with no more than three full time equivalent (FTE) APRNs. Under SB 724, this 3 FTE limitation applies to all collaborative practice agreements involving APRNs (except for APRNs employed by hospitals and treating only inpatients, as well as APRNs employed by population based public health services).

Also, under the existing collaborative practice regulations, only those practices where the APRN is engaged in the diagnosis and initiation of treatment for acutely, chronically ill or injured patients is the APRN required to practice at the same location as the collaborating physician for at least one calendar month before the APRN can practice at a location where the physician is not present. Under SB 724, collaborating physicians must determine and document the completion of a period of at least one month during which the APRN practices with the collaborating physician continuously present before the APRN practices at any location where the collaborating physician is not continuously present. This provision applies to all APRNs, regardless of the type of practice, except for APRNs working in population based public health services.

Miscellaneous Provisions

No physician can be required by contract or other agreement to collaborate with an APRN against the physician's will. No APRN can be required by contract or other agreement to collaborate with a physician against the APRN's will. Both have the right to refuse such collaborations without penalty.

SB 724 inserted "registered" into the title of advanced practice registered nurse. It also excludes from qualification as an APRN, those nurses practicing in specialties that do not have a recognized specialty board to certify them, even if the nurse has advanced education, training and experience.

While we will have to wait for the rules and regulations to be adopted before APRNs will be able to prescribe controlled substances, many other provisions of SB 724 do not require the adoption of regulations and will soon become part of the law of collaborative practice. All APRNs should review their existing CPAs and take action to bring them into compliance by August 28, 2008.
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Author:Watters, Richard D.
Publication:Missouri Nurse
Geographic Code:1U4MO
Date:Jan 1, 2008
Previous Article:Senate Bill 724.
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