NURSE PRACTITIONERS

Number of Nurse Practitioners That May Be Supervised by One Physician:  Under California Business and Professions Code section 2836.1(e), a physician may supervise up to four (4) nurse practitioners (NPs) that furnish drugs or devices. There are no other limits on the number of NPs that a physician may supervise.

Scope and Supervision of Nurse Practitioner Practice:  NPs are authorized by law to perform all the functions of a registered nurse (RN), including: direct and indirect patient care to ensure safety, comfort, and personal hygiene; performance of disease prevention and restorative measures; the administration of medication and therapeutic agents to patients pursuant to a physician’s orders; and the performance of skin tests, immunizations, and blood withdrawals.[1]

NPs and RNs may also perform “standardized procedures” (SPs).  SPs allow an NP to perform functions that ordinarily would be considered the practice of medicine.  Pursuant to an SP, however, an NP may observe signs and symptoms of illness, reactions to treatment, and general physical and mental condition, and based thereupon may implement an SP, such as a change in treatment regimen or initiation of emergency procedures.[2]

The Board of Registered Nursing and the Medical Board of California promulgated regulations outlining the appropriate manner in which SPs may be created.  The regulations require each SP to:

(1) Be in writing, dated and signed by the organized health care system personnel authorized to approve it.

(2) Specify which standardized procedure functions registered nurses may perform and under what circumstances.

(3) State any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions.

(4) Specify any experience, training, and/or education requirements for performance of standardized procedure functions.

(5) Establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions.

(6) Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions.

(7) Specify the scope of supervision required for performance of standardized procedure functions, for example, immediate supervision by a physician.

(8) Set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient’s physician concerning the patient’s condition.

(9) State the limitations on settings, if any, in which standardized procedure functions may be performed.

(10) Specify patient record keeping requirements.

(11) Provide for a method of periodic review of the standardized procedures.[3]

Most significant, the fourth and fifth criteria above create a requirement that an NP must be competent to perform the procedure, (including competency in education, experience, and training) regarding the SP.   Physician supervision is also important, especially considering the degree of  difficulty and risk for any given SP.

NPs may also furnish and order drugs and devices to and for patients pursuant to an SP (if an NP is furnishing controlled substances, however, the NP must first obtain a DEA license).  Such an SP must specify: which NPs may order and furnish drugs and devices, which drugs and devices may be ordered and furnished, the extent of physician supervision required, the method for periodically reviewing the NPs competence in the area, and the method for periodically reviewing the SP.[4] The NP must have educational preparation and clinical competency to furnish or order any particular drug or device.[5]  Finally, physician supervision does not require physical presence, but does require collaboration on development of the SPs, approval of the SPs, and telephonic availability during a NPs implementation of an SP.[6]

Furthermore, California law specifically authorizes NPs to perform the following SP: order durable medical equipment, perform a physical examination and certify an individual as disabled, and approve, sign, and modify treatment plans for individuals receiving home health care.[7]  Physician supervision is required.

PHYSICIAN ASSISTANTS

Number of Physician Assistants That May Be Supervised by One Physician

Under California Business and Professions Code section 3516, a physician may supervise no more than four (4) physician assistants (PAs) at any one time.

Scope and Supervision of Physician Assistants Practice

A PA may perform medical services that he or she is (a) competent to perform as demonstrated by experience, education, and training, and (b) are delegated to the PA by a physician pursuant to a “Delegation of Services Agreement” (DSA).[8]  A PA may provider services for multiple physicians, either pursuant to a joint DSA or separate DSAs (i.e., a PA mat be supervised by more than one physician).

DSAs may designate the following services: (1) taking of patient history, performance of physical exam and assessment and diagnosis therefrom, and initiate, review and revise treatment plans; (2) order x-rays, therapeutic diets, physical therapy, occupational therapy, respiratory therapy, and nursing care; (3) order or perform laboratory, screening, or therapeutic procedures; (4) provide emergency treatment; (5) refer patients to other health facilities and agencies; (6) administer or order drugs pursuant to a policy created by a supervising physician (such policy must include: specifications of all criteria for the use of a particular drug, and for Schedule II drugs the diagnosis, illness, or condition for which they may be administered); and (7) perform surgical procedures without the presence of a physician under local anesthesia, and perform surgical procedures in the presence of a physician under other types of anesthesia.[9]

For all services rendered by a PA pursuant to a DSA a physician must provide adequate supervision.  This entails that (1) the supervising physician is available in person or by electronic communication whenever the PA renders services; (2) only tasks consistent with the supervising physician’s practice are delegated to the PA; (3) the supervising physician must review or observe the PA performing delegated tasks until he or she is satisfied with the PA’s competence; (4) the supervising physician and PA develop procedures in case of an emergency situation beyond the PA’s competence; (5) the supervising physician must either exam patients records on the same day a PA renders services or countersign and date all patient records within thirty (30) days of PA furnishing care; and (6) the supervising physician has final responsibility for patients (i.e., the PA is not autonomous).[10]

While California Corporations Code Section 13401.5 governs who can own stock in various “healing arts” professional corporations, it also governs whom the various “healing arts” professional corporations may employ.

California Business and Professions Code Section 13401.5 states: “the following licensed person may be . . . professional employees of the professional corporations designated in this section,”  and then includes the various “healing arts” professional corporations and which professional employees they may employ. Medical corporations may employ physician assistants.  Nursing corporations may employ physician assistants.  Physician assistant corporations may employ physician assistants.  Acupuncture corporations may employ physician assistants.  Finally, Naturopathic doctor corporations may employ physician assistants. Section 13402.5 does not list physician assistants as allowable professional employees of a chiropractic corporation.