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Physician's Guide to Medicine - Collaborative Practice Arrangements
Purpose: This rule defines collaborative practice arrangement terms and
delimits geographic area; methods of treatment; review of services; and
drug/device dispensing or distribution pursuant to prescription.
(1) For the purpose of these rules, the following definitions shall apply:
(A) Advanced practice nurse - a registered professional nurse who is also an
advanced practice nurse as defined in section 335.016 (2), RSMo;
(B) Collaborative practice arrangements - refers to written agreements, jointly
agreed upon protocols, or standing orders, all of which shall be in writing, for
the delivery of health care services; and
(C) Registered professional nurse - a registered professional nurse as defined
in section 335.016(9), RSMo, who is not an advanced practice nurse.
(2) Geographic Areas
(A) The collaborating physician in a collaborative practice arrangement shall
not be so geographically distanced from the collaborating registered
professional nurse or advanced practice nurse as to create an impediment to
effective collaboration in the delivery of health care services or the adequate
review of those services.
(B) The use of a collaborative practice arrangement by an advanced practice
nurse who provides health care services that include the diagnosis and
initiation of treatment for acutely or chronically ill or injured persons shall
be limited to practice locations where the collaborating physician, or other
physician designated in the collaborative practice arrangement, is no further
than fifty (50) miles by road, using the most direct route available, from the
collaborating advanced practice nurse if the advanced practice nurse is
practicing in federally designated health professional shortage areas (HPSAs).
Otherwise, in non HPSAs, the collaborating physician and collaborating advanced
practice nurse shall practice within thirty (30) miles by road of one another.
The provision of the above specified health care services pursuant to a
collaborative practice arrangement shall be limited to only an advanced practice
nurse.
(C) An advanced practice nurse who desires to enter into a collaborative
practice arrangement to provide health care services that include the diagnosis
and treatment of acutely or chronically ill or injured persons at a location
where the collaborating physician is not continuously present shall practice at
the same location with the collaborating physician for a period of at least one
(1) calendar month before the collaborating advanced practice nurse practices at
a location where the collaborating physician is not present. The provision of
the above specified health care services pursuant to a collaborative practice
arrangement shall be limited to only an advanced practice nurse.
(3) Methods of Treatment
(A) The methods of treatment and the authority to administer, dispense, or
prescribe drugs, delegated in a collaborative practice arrangement between a
collaborating physician and collaborating registered professional nurse or
advanced practice nurse shall be within the scope of practice of each
professional and shall be consistent with each professional´s skill, training,
education, and competence.
(B) The collaborating physician shall consider the level of skill, education,
training, and competence of the collaborating registered professional nurse or
advanced practice nurse and ensure that the delegated responsibilities contained
in the collaborative practice arrangement are consistent with that level of
skill, education, training, and competence.
(C) The methods of treatment and the authority to administer, dispense, or
prescribe drugs delegated to the collaborating registered professional nurse or
advanced practice nurse in a collaborative practice arrangement shall also be
consistent with the scope of practice of the collaborating physician.
(D) Guidelines for consultation and referral to the collaborating physician or
designated health care facility for services or emergency care that is beyond
the education, training, competence, or scope of practice of the collaborating
registered professional nurse or advanced practice nurse shall be established in
the collaborative practice arrangement.
(E) The methods of treatment and authority to administer, dispense, or prescribe
drugs delegated to the collaborating registered professional nurse or advanced
practice nurse in a collaborative practice arrangement shall not be further
delegated to any other person except that the individuals identified in section
338.095 and 338.198, RSMo may communicate prescription drug orders to a
pharmacist.
(F) The methods of treatment, including any authority to administer or dispense
drugs, delegated in a collaborative practice arrangement between a collaborating
physician and a collaborating registered professional nurse shall be delivered
only pursuant to a written agreement, jointly agreed-upon protocols, or standing
orders that shall describe a specific sequence of orders, steps, or procedures
to be followed in providing patient care in specified clinical situations.
(G) The methods of treatment, including any authority to administer, dispense,
or prescribe drugs, delegated in a collaborative practice arrangement between a
collaborating physician and a collaborating advanced practice nurse shall be
delivered only pursuant to a written agreement, jointly agreed upon protocols,
or standing orders that are specific to the clinical conditions treated by the
collaborating physician and collaborating advanced practice nurse.
(H) The collaborative practice arrangement between a collaborating physician and
a collaborating registered professional nurse or advanced practice nurse shall
be signed and dated by the collaborating physician and collaborating registered
professional nurse or advanced practice nurse before it is implemented,
signifying that both are aware of its content and agree to follow the terms of
the collaborative practice arrangement. The collaborative practice arrangement
and any subsequent notice of termination of the collaborative practice
arrangement shall be in writing and shall be maintained by the collaborating
professionals for a minimum of eight (8) years after termination of the
collaborative practice arrangement. The collaborative practice arrangement shall
be reviewed and revised as needed by the collaborating physician and
collaborating registered professional nurse or advanced practice nurse.
(I) Methods of treatment delegated and authority to administer, dispense, or
prescribe drugs shall be subject to the following:
(1) The physician retains the responsibility for ensuring the appropriate
administering, dispensing, prescribing and control of drugs utilized pursuant to
a collaborative practice arrangement in accordance with all state and federal
statutes, rules, or regulations;
(2) All labeling requirements outlined in Section 338.059, RSMo shall be
followed;
(3) Consumer product safety laws and Class B container standards shall be
followed when packaging drugs for distribution;
(4) All drugs shall be stored according to the United States Pharmacopeia (USP)
recommended conditions;
(5) Outdated drugs shall be separated from the active inventory;
(6) Retrievable dispensing logs shall be maintained for all prescription drugs
dispensed and shall include all information required by state and federal
statutes, rules, or regulations;
(7) All prescriptions shall conform to all applicable state and federal
statutes, rules, or regulations and shall include the name, address, and
telephone number of the collaborating physician and collaborating advanced
practice nurse;
(8) A registered professional nurse shall not, under any circumstances,
prescribe drugs;
(9) An advanced practice nurse shall not, under any circumstances, prescribe
controlled substances. The administering or dispensing of a controlled substance
by a registered professional nurse or advanced practice nurse in a collaborative
practice arrangement shall be accomplished only under the direction and
supervision of the collaborating physician, or other physician designated in the
collaborative practice arrangement, and shall only occur on a case-by-case
determination of the patient´s needs following verbal consultation between the
collaborating physician and collaborating registered professional nurse or
advanced practice nurse. The required consultation and the physician´s
directions for the administering or dispensing of controlled substances shall be
recorded in the patient´s chart and in the appropriate dispensing log. These
recordings shall be made by the collaborating registered professional nurse or
advanced practice nurse and shall be co-signed by the collaborating physician
following a review of the records;
(10) An advanced practice nurse or registered professional nurse in a
collaborative practice arrangement may only dispense starter doses of medication
to cover a period of time for seventy-two (72) hours or less with the exception
of Title X family planning providers or publicly funded clinics in community
health settings that dispense medications free of charge. The dispensing of drug
samples, as defined in 21 U.S.C. Section 353 © (1), is permitted as appropriate
to complete drug therapy; and
(11) The medications to be administered, dispensed, or prescribed by a
collaborating registered professional nurse or advanced practice nurse in a
collaborative practice arrangement shall be consistent with the education,
training, competence, and scopes of practice of the collaborating physician and
collaborating registered professional nurse or advanced practice nurse.
(J) When a collaborative practice arrangement is utilized to provide health care
services for conditions other than acute self-limited or well defined problems,
the collaborating physician, or other physician designated in the collaborative
practice arrangement, shall see the patient for evaluation and approve or
formulate the plan of treatment for new or significantly changed conditions as
soon as is practical, but in no case more than two (2) weeks after the patient
has been seen by the collaborating advanced practice nurse or registered
professional nurse.
(K) Nothing in these rules shall be construed to permit medical diagnosis of any
condition by a registered professional nurse pursuant to a collaborative
practice arrangement.
(4) Review of Services
(A) In order to assure true collaborative practice and to foster effective
communication and review of services, the collaborating physician, or other
physician designated in the collaborative practice arrangement, shall be
immediately available for consultation to the collaborating registered
professional nurse or advanced practice nurse at all times, either personally or
via telecommunications;
(B) The collaborating physician shall review the work, records, and practice of
the health care delivered pursuant to a collaborative practice arrangement at
least once every two (2) weeks. This review shall be documented by the
collaborating physician. This subsection shall not apply to the situation
described in subsection (4) (E) below or during the time the collaborating
physician and collaborating advanced practice nurse are practicing together as
required in subsection (2) © above;
© If a collaborative practice arrangement is used in clinical situations where a
collaborating advanced practice nurse provides health care services that include
the diagnosis and initiation of treatment for acutely or chronically ill or
injured persons, then the collaborating physician shall be present for
sufficient periods of time, at least once every two (2) weeks, except in
extraordinary circumstances that shall be documented, to participate in such
review and to provide necessary medical direction, medical services,
consultations, and supervision of the health care staff. In such settings the
use of a collaborative practice arrangement shall be limited to only an advanced
practice nurse and the physician shall not enter into a collaborative practice
arrangement with more than three (3) full-time equivalent advanced practice
nurses;
(D) The collaborating physician and collaborating registered professional nurse
or advanced practice nurse shall determine an appropriate process of review and
management of abnormal test results which shall be documented in the
collaborative practice arrangement;
(E) In the case of collaborating physicians and collaborating registered
professional nurses or advanced practice nurses practicing in settings which
provide care to well patients or to those with narrowly circumscribed conditions
in public health clinics or community health settings that provide population
based health services limited to immunizations, well child care, human
immunodeficiency virus (HIV) and sexually transmitted disease care, family
planning, tuberculosis control, cancer and other chronic disease and wellness
screenings, services related to epidemiologic investigations and prenatal care,
review of services shall occur as needed and set forth in the collaborative
practice arrangement. If the services provided in such settings include
diagnosis and the initiation of treatment of any other disease or injury, then
the provisions of subsection (4) © shall apply;
(F) The process and documentation of review shall be on
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